Personalized Individual/Family Health Quote

If you do not have employer group benefits, are self employed, retired or a student
looking for a new individual or family health plan.

Part I Contact Information (all fields marked with an * must be filled in to continue)

First Name *

Last Name *

Email Address *

Phone Number

use format xxx -xxx-xxxx

Best Time to Call

Street Address *

Apt. #

City *

State

Zip*

County

Association Status*

Current Member

Prospective Member

Deliver my quote by*	E-mail	Fax	( ) -
	Regular Mail	Call with information

Part II Plan & Family Information

Which of these three statements most accurately describes the characteristics of a health insurance plan that appeals to you? (select one)

I am not too concerned about everyday medical expenses, but I want very good coverage for catastrophic losses. (lowest cost plans)

I would like very good coverage for services such as doctor visits, emergencies and prescriptions, but I would accept a higher deductible for inpatient services in return for a more affordable premium.
(mid-range plans)

I want a plan with very comprehensive coverage for inpatient and outpatient services, with very little out-of-pocket costs. (highest cost plans)

Would you like optional Maternity benefits? Yes No

Information about you and your family.
List family members only if inquiring about rates for them

Relationship	Date of Birth or Age	Sex	HT?	WT?	Smoker?
		M F
		M F
		M F
		M F
		M F
		M F
		M F

Would you like to receive e-mail on new products or services we offer?

Yes No

Questions/Comments

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WORLDWIDE INSURANCE SERVICES, INC. All Rights Reserved © 2002-2009
25775 N. Hillview Ct. Suite B
Mundelein, IL 60060
Phone: 800-955-0418 Fax 866-967-6310
Alan A Leafman, Agent state of domicile and
principal place of business IL -CA lic# OB98320