Health Quote – Empower Brokerage

Instructions

Fill out the form below as completely as possible. An Empower agent will then contact you with the lowest possible price based on the information you provide.

Step 1

Insured Information

First Name (required)

Last Name (required)

Street Address

Apartment/Suite #

City

State

Zip

Home Phone

Work Phone

...Ext.

Fax Number

Sex

Date of Birth

Age

Height

ft.

in.

Weight

lb.

Occupation

Employer's Phone

Employer's Fax

Do you use other tobacco products?

Are you a smoker?

Step 2

Spouse Information

Will your spouse need coverage?

First Name (required)

Last Name (required)

Sex

Date of Birth

Age

Height

ft.

in.

Weight

lb.

Occupation

Employer's Phone

Employer's Fax

Do you use other tobacco products?

Are you a smoker?

Step 3

Children Information

How many of your children will need coverage?

Child #1

First Name

Last Name

Sex

Date of Birth

Age

Height

ft.

in.

Weight

lb.

Do you use other tobacco products?

Are you a smoker?

Child #2

First Name

Last Name

Sex

Date of Birth

Age

Height

ft.

in.

Weight

lb.

Do you use other tobacco products?

Are you a smoker?

Child #3

First Name

Last Name

Sex

Date of Birth

Age

Height

ft.

in.

Weight

lb.

Do you use other tobacco products?

Are you a smoker?

Child #4

First Name

Last Name

Sex

Date of Birth>

Age

Height

ft.

in.

Weight

lb.

Do you use other tobacco products?

Are you a smoker?

Child #5

First Name

Last Name

Sex

Date of Birth

Age

Height

ft.

in.

Weight

lb.

Do you use other tobacco products?

Are you a smoker?

Step 4

Coverage Needed

Individual Health

Short-Term Medical

Dental

Disability

Long-Term Care

Medical History

If you have or have had any of the conditions listed below, please select that condition and to the right give a brief history and list treatments.

Heart Circulation Problems/HBP/Stroke

Lung disorder/Asthma

Cancer (inc. skin)

Diabetes: diet control/oral meds/insulin

AIDS/ARC

Mental/Nervous/A.D.D

Alcohol/Drug disorder

Medical expense of $5000+ in the last year

Pregnancy/Disability

Hazardous hobbies (ie flying, skydiving)

Auto/Boat/Motorcycle/Dirt-bike racing

Mountain-climbing/Scuba Diving/Other

List any current medications

Sales Agent Name

Agent Email

Agent Phone

Please verify that all the information you have entered is correct.Then click the Submit Quote Info button to send us your request for a quote

By checking this box, you consent to receive text messages from Empower Brokerage and/or a licensed Empower Brokerage agent. These messages may include marketing messages (e.g., promotions, reminders) and follow-up communications related to your inquiry to the number provided, which may include the use of an autodialer. Message and data rates may apply. Message frequency varies. You can unsubscribe at any time by replying STOP or clicking the unsubscribe link.

By clicking and submitting this form with my name, phone number, and e-mail address, I agree that I am at least 18 years of age. By clicking and submitting this form, I understand that I am enrolling in an ongoing marketing campaign about insurance services and other options from Empower Brokerage or a licensed agent, and I will receive phone calls and e-mails (even if that phone number is on any Do Not Call Registry or is a mobile number). If you want to opt out of receiving future e-mails from Empower Brokerage, you can do so at any time by clicking the “unsubscribe” button in our e-mail.

For more details, see our Terms and Conditions and Privacy Policy.

Standard text and data rates may apply. You can opt out of receiving text messages from Empower Brokerage at any time by replying to an Empower Brokerage text message with “unsubscribe”, “stop”, “end”, “no”, or “opt out”. If you want to opt out of receiving future e-mails from Empower Brokerage, then you can do so at any time. Please click the “unsubscribe” button in our e-mail. Empower Brokerage values your privacy and will not share your personal information with any other business or persons.