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As soon as I receive your request I will be working on your quote. I may need to contact you to verify your information to make sure I am able to give you the most accurate quote.
All of your information is seen only by me, Jeffrey Pratt, a licensed insurance agent, and is kept strictly confidential. It is used for the sole purpose of obtaining an accurate insurance quote and is not shared with any other party.
Unlike other insurance sites, by filling out this form you will only be contacted by Jeffrey Pratt.
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Get A Quote!
Need Help? Have Questions?
1-888-663-5900
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*Home Phone:
City:
Street Address:
*Last Name:
*First Name:
* Required Information
Alternate Phone:
*Email:
Contact me by:
Birth Date:
Gender:
Health Information
Do you currently take any prescription medications?
If yes, please list medication name, dosage and frequency:
Have you been diagnosed with the following conditions in the past 10 years?
If you've selected any of the above, please provide date of onset, diagnosis, and current status:
When did you last use tobacco products?
Are you an expectant mother or father?
Height
Weight
Would you like to add a spouse to your quote?
If yes, please fill in the following information:
Spouse's Birth Date:
Spouse's Gender:
Spouse's Height:
Spouse's Weight:
Spouse's Last Tobacco Use:
Please list any health conditions and prescription:
Would you like to add a children to your quote?
If yes, please fill in the following information:
Child 1 Birth Date (MM/DD/YYYY):
Child 2 Birth Date (MM/DD/YYYY):
Child 3 Birth Date (MM/DD/YYYY):
Child 4 Birth Date (MM/DD/YYYY):
Coverage Information
Are you currently insured?
Name of current company:
Please tell me what type of plan you're most interested in:
Office co-pays, prescription co-pays, catastrophic, HSA?
Are you Self Employed?
Are you currently covered by COBRA?
Would you also like a Life Insurance Quote?
Amount of Coverage:
If your request is urgent, please call!
Health Insurance
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American Insurance Advisors
Personalized Plans, Superior Service
*Zip:
State:
When would you like your new coverage to begin?
