P.O. Box 33341
Washington, DC. 20033
Tel: (202)296-8614
Toll-free 1-800-964-8614
Fax: (202)296-6333
E-mail: info@paulbalep.com

Individual Health Insurance Quotes Request Form

<<Independence is number one>>. We are nonexclusive producers who represent an average of eight companies-not just one. Paul Balep can evaluate and compare the products of several fine companies to find you the right combination of coverage and value.

Individual Profile

To help our insurance representatives better understand your individual health insurance needs, please complete the following form below and click the “Submit” button for a free, no-obligation quote. A PaulBalep representative will call you to set up a meeting to discuss your insurance and financial goals.

Privacy Notice: All information you provide is solely used for the purpose of providing you with quotes. We will never sell, give, or otherwise transfer your personal information to any person or entity other than the insurance companies, agents, and representatives selected. In some cases insurance companies we work with may request credit score.

Please enter the contact person's first and last name who will be responsible for processing the quotes:
FirstLast
Will this insurance replace an existing heatlh insurance policy? Yes No

What is the name of your current health insurance company?

Current plan type: HMO(Health Maintenance Organization) POS(Point-of-Service) PPO(Preferred Provider Organization)
What is your current Co-pay: $5 $10 $15 $20 $25
What is your current deductible: None $500 $1,000 $1,500 $2,500 $5,000 $10,000

How long, in years, have you had health insurance with this company?

How long have you had continuously health insurance coverage (With no lapse)?

How much do you currently pay for your insurance? $

How often do you pay that premium? Monthly Quarterly Every Six Months Yearly
If you do not have coverage please indicate when you would like a policy to go into effect: Immediately 15 Days 30 Days Other

Requested Individual Health Insurance Coverages

What type of health insurance coverages are you interested in? HMO (Health Maintenance Organization) POS (Point-of-Service) PPO (Preferred Provider Organization) Not Sure
Please choose the preferred Co-pay amount

$5 $10 $15 $20 $25 Not Sure

What deductible amount do you want? $500 $1,000 $1,500 $5,000 $10,000 Not Sure
What optional coverages would you like? Prescriptions Dental Vision Care Wellness
Are you in need of maternity coverage? Yes No
Are you currently pregnant? Yes No
Gender: Male Female

Date of Birth:

Height:

ft. in.

Weight:

 lbs.
Marital Status:

Single Single-Parent Married Separated Divorced Widowed

Highest Grade Level

None or Incomplete Education High School Diploma GED Some College College Degree Masters Degree PHD

Please tell us your current work status:

Full Time Part Time In Transition Retired Homemaker Student Other

Occupation:

How long have you been at your present job?

Years Months
Are you covered by a workers' compensation program? Yes No
During the past 5 years, when was the last time that you used any form of tobacco or a nicotine substitute?
Never 1-12 month(s) 13-24 months 25-36 months 37-48 months 49-60 months
If Yes, what forms of tobacco did you use? Smoke Cigarettes Smoke Cigars Smoke a Pipe Chew Tobacco Chew Nicotine Gum The Patch
If you currently smoke cigarettes, how many packs daily? None Under 1 1 To 2 Over 2
Have you used any form of alcoholic / substitute in the past five years? Yes No
If Yes, do you drink? Beer Wine Liquor
Any DUI or DWI in the last 5 years? Yes No
Have you been hospitalized in the last 5 years? Yes No
Currently taking any prescription medications? Yes No
Have you ever had any indication of the following medical problems?
Heart Disease: Yes No Cancer: Yes No HIV: Yes No
Diabetes: Yes No Cholesterol: Yes No High Blood Pressure: Yes No
What range describes your approximate household income: Less than $25k $25-40k $41-60k $61-80k $81-100k $101-150k $151-200k $201-300k Over $300k
Do you own or rent your residence: Rent Own Other
Time at current residence: Less than 1 Year 1-5 Years 5-10 Years 10-20 Years Over 20 Years

Please describe your credit history:

Major Problems Some Problems Good Some Lates Excellent Don't Know
Please enter further information or questions about desired coverages:
Insurance Information
Please tell us more about your current or recent insurance policy. Be as accurate as possible.
Your most current insurance company? (You won't receive a quote from this company)
What date does your current policy expire/renew?
How long have you been insured with your current insurance company?
Years Months
Extremely important: How long have you been continuously insured?
Years Months
Contact Information
In most cases, the insurance companies we work with will send you your quotes via email. In some cases, when additional
information is needed, they will need to speak with you personally. Please provide valid contact information as requested below.
First Name: Last Name:
Street Address: Apt or Unit :
City: Country:
State: Zip Code:
Please enter a valid E-Mail address:
Business Telephone Number:
Contact Telephone Number: Ext:
Fax Number:
If necessary, best time of day to contact you? Anytime Morning Afternoon Evening
How quickly do you need your request processed? Day(s)
Please provide any comments you have for the agents who respond to this quote request:
DISCLOSURE:
Where permitted by law, some insurance companies may confirm your information, through the use of consumer
reports, which may include credit score and driving record.
By submitting this information, I request that insurance companies subscribing to the PaulBalep quote service contact me with quotes via email, telephone and fax using the information I have provided.
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