Benefits Consultants

Tim B. Piatchek, LUTCF, LC

Serving the Ozarks and

Southwest Missouri

since 1968!

Call us locally at 417-877-1567 or Toll-Free at 866-716-4555

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Individual Health Plan

 

Group Health Plan

 

Term Life Insurance

 

IRA - Annuities - 401K Rollover - Retirement Planning

 

 

 

 

 

 

 

   Individual Health Plans

The quote you are requesting requires that you complete the following survey as completely and accurately as possible.  Once submitted, your information is e-mailed to our office and we will process your request.  This information is kept confidential and used for quote purposes only.

   *Required fields marked in yellow

Contact Information
*Name:
*Address:
*City:  State:  Zip:
*Phone: Work:
 
Home: 
   
 Fax: 
Occupation:
Email Address:

 

Type of Coverage

 Doctor Visit Copay: Yes   No
Hospital Deductible:

Coinsurance:
Health System Preference:
Optional Coverage: Maternity Prescription Card
Supplemental Accident
List any specific companies you would like quotes from:
List any major medical conditions associated with any individual/dependents listed below:
(cancer, diabetes, heart)

List any prescription medications

associated with any individual/dependents listed below:
 

 

Census Information

Please list all individuals (you, your spouse and dependents) you wish to cover.

Name

Date of Birth

Age

Gender

Detail

 

 

 

 

 

 

 

 

 

 Male
Female

 

 

 

 Height:
ft.in.
Weight:lbs.
Smoker?
Yes
No

 

 

 

 

 

 

 

 

 

 

 Male
Female

 

 

 

 Height:
ft. in.
Weight:lbs.
Smoker?
Yes
No

 

Male
Female		 Height:
ft. in.
Weight:lbs.

Male
Female		 Height:
ft. in.
Weight:lbs.

Male
Female		 Height:
ft. in.
Weight:lbs.

Male
Female		 Height:
ft. in.
Weight:lbs.

Male
Female		 Height:
ft. in.
Weight:lbs.

Male
Female		 Height:
ft. in.
Weight:lbs.

If you have more than 6 children, just submit this form additional times.  On the additional submissions, only enter your name and the childrens' information as needed.

 

Additional Considerations/Requests
Please add any comments/questions not covered above.


Please click on the "Send Request" button to send us your quote request.

  

 

 

 

 

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