Sheridan Agency Health
Insurance Quote Form
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It only takes a few minutes!
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Referred By:
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Choose the Sheridan location
nearest you: (Required)
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Your Personal Data
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First & Last Name: (Required)
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Street Address:
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City:
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State:
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Zip Code:
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E-Mail (required):
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E-Mail (re enter):
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Phone:
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Fax:
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Marital Status:
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Gender:
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Currently Insured?:
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If yes, list carrier, and
describe coverage. |
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UNDERWRITING INFORMATION
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List children's names (First & Last)
and their relationship to you:
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(List up to six children.)
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Be as specific as you can on the underwriting questions below so we may find the most competitive product for you!
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Does any family member living in the household use or has used any tobacco products? (if yes give dates, and details in remarks section).
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If yes, give detail:
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Pre-existing Health Conditions.
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If yes, describe in detail and to which of the insured persons they apply.
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Any Covered Persons Currently Taking Medication of Any Kind.
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If yes, describe in detail and to which of the insured persons they apply.
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If you're looking to reduce premium cost, and want information on the NEW HSA (Health Savings Plans), select "Yes" and we'll include information.
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Include HSA Information:
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What do you want most in your health plan?
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Comments or Questions:
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Send my Health Insurance
Quote by:
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We treat all your responses as private information. We will not give your data to any other person or group for any purpose. Although it is our intent to keep your information private, we cannot guarantee that it will not be viewed by others accidentally. Our online quote forms are to provide current and prospective clients an estimated premium only. No coverage can be bound by this process until original applications, signatures and premium are received and submitted to the insurance company for underwriting.
If you agree, please select YES and click the Submit button so that we can get to work on getting you your quote.
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I agree, send my quote! (Required)
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Please, only click once.
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