Health Insurance Quote

 from 

Products and services offered by the Eck Agency may not be available in all states. This information shall not constitute an offer in any state in which a product or company is not properly registered or licensed. The Eck Agency generally offers and sells its products and services only in the states of Kansas and Oklahoma. This information shall not constitute an offer in any foreign country.  All quotes are subject to underwriting and may not be available in all states.

 

Please complete the following: (all information is confidential and will be used only for the purpose of providing you with the requested quote)  THIS IS NOT AN INSTANT QUOTE.  INSTANT QUOTES ARE USUALLY MISLEADING.  ONE OF OUR SPECIALISTS WILL CONTACT YOU.

Type of Coverage Major Medical    Cancer       Disability 
State
First Name (Required)
Last Name (Required)
Street Address (Required)
City/County (Required)
Zip/Postal Code (Required)
E-mail 
Home Phone (Include area code)  AT LEAST ONE PHONE NUMBER IS REQUIRED
Work Phone (Include area code)
Cell Phone (Include area code)
Date of Birth (Required)
Sex Male Female (Required)
Height/Weight (Required)       (Required)
Use Tobacco? No  Yes (Required)
Do you want dependents covered?

ALL INFO IS REQUIRED IF YOU WANT A QUOTE

 
Spouse Name Date of Birth Tobacco No  Yes
Ht      Wt      
Children Date of Birth
#1
#2
#3
#4
Do you currently have coverage? Yes  No

Indicate what coverage you are requesting:

Select any of the following options that apply

 
Deductible
$500 $1000 $1500 Other Amount 
Drug Card  Yes  No
Supplemental Accident Yes  No
Maternity    Yes  No
Any current health conditions 
Describe any health conditions for which you or your dependents are being or have recently been treated:
Current Medications 

 
List any current prescription drugs that you or your dependents are taking, include the dosages and the condition for which they are being taken:

 

Copyright ©2000 Eck Agency, Inc  All rights reserved.
Revised: April 29, 2008