America's HealthPlan Consultants
Request Quote

Our representatives are trained, licensed and appointed on every product we sell. We have helped thousands of individuals choose their health insurance. We will shop various insurance companies to find the lowest priced benifits that best fit your needs.

Please complete the following information to obtain your NO OBLIGATION insurance quote. We will contact you promptly.

For immediate assistance call Toll-Free 1-877-899-5325 8:00 a.m. - 5:00 p.m. CDT.


Zip Code:
(Required)
Name:
(Required)
 
Daytime Phone:
(Required)
Evening Phone:
E-mail:
(Required)
 
       
All of the following information is required to give you a quote.
People Covered
Gender
Birthdate
mm/dd/yyyy
Tobacco use in
the last 12 months
Height and Weight
Self
Male        Female
None        Yes
FT. IN. LBS.
         
       
ANNUITIES
     
       
Approximate amount you want to invest
   
     
Do you want to invest in something with a:

Guaranteed Return

Variable Return

Combination of Both

   
       
 
LIFE INSURANCE
     
       
Face amount of policy
   
     
Type of policy you want:
Term Life
Whole Life
Universal Life
Do not know
       
Most Life Insurance requires a detailed history, to obtain the best rates.
To start this process answer the following questions.
     
Have you had any sugeries in the last 10 years?
Yes        No
   
     
Briefly describe:
 
     
Are you diabetic?
Yes
No
       
Do you have high blood pressure?
Yes
No
   
       
Do you have high cholesterol?
Yes
No
   
   
   
FINAL EXPENSE
       
Face amount of policy:
   
       
DISABILITY
       
What is your occupation?
   
What is your income?
   
       
LONG-TERM CARE
       
Are you married?
Yes
No
   
Is this for yourself or a couple?
Myself
Couple
   
       
Notes: We can only provide initial premium quotes with the information at hand. Final rates will be provided by the insurance carrier based on your completed application.

We do not sell or otherwise share this information outside our company. Privacy Policy