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 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*
     
     
 Part II Plan 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)
         
  Information about you and your family.
List Spouse only if inquiring about rates for Him/Her
 
Relationship
Date of Birth or Age
Sex
HT?
WT?
Smoker?
M F
M F
   
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Questions/Comments
   
 
 

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WORLDWIDE INSURANCE SERVICES, INC. All Rights Reserved © 2002-2008
237 Melvin Drive
Northbrook, IL 60062
Phone: 800-955-0418 Fax 847-559-9499

Alan A Leafman, Agent state of domicile and
principal place of business IL -CA lic# OB98320

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