Health Insurance

Looking for affordable health insurance?
Reed & Baur can help. We'll work overtime to get the perfect health insurance policy for your needs and budget.

Please take a minute to share your information using the form below and we'll find the ideal situation for you. All fields are optional and if you're in a hurry just fill out the first section. One of our friendly agents will contact you shortly. Thank you!

Request for Individual Health Insurance
Section A
Name
Phone #
Email Address

City
State		Zip

County

Self-employed?

Yes No

Date of birth	//	Height	' "	Weight
Spouse's DOB	//	Height	' "	Weight

Number of children		Children's ages
Current coverage?	Yes No	Current carrier
Deductible(s)     $500    $1000    $1500    $2500    $5000    MSA
Co-insurance percentage(s)     80/20    90/10    network (ppo)
Additional benefits accident    life    Rx card    dental    vision    $500 professional serv.
Validation Code
Please enter the 5 character verification code:
Only click here if you're NOT filling out Section B below.

Section B
Medical Information
1. Has the insured or any eligible dependent for insurance ever been diagnosed / treated for AIDS, cancer, diabetes, heart problems, high blood pressure, ulcers, kidney, obesity, stroke, colitis, infertility of any other medical condition?	Yes No
If yes, please explain in detail (list medications WITH dosages and any treatments for above listed conditions)
2. Is insured or dependents pregnant?	Yes No
3. Is client a tobacco user?	Yes No
3a. Is spouse a tobacco user?	Yes No
4. Has insured or dependents had or contemplating surgery?	Yes No
If yes, please explain in detail
Validation Code
Please enter the 5 character verification code: