Physical address:
Phillip R Davis & Assoc Inc.
1623 W Centre Ave
Portage Mi. 49024

Mailing address:
Phillip R Davis & Assoc Inc.
P.O. Box 1836
Portage Mi. 49081-1836

Agency: 269.327.1622

Toll Free: 800.642.4431

Fax: 269.327.1673

prdavis@tds.net

Ashley Gibney

269.492.3156
Email Ashley

Melanie Littell

269.492.3157
Email Melanie

Nancy Nap

269.492.3158
Email Nancy

Michelle Clark

269.327.1622
Email Michelle

Individual & Family Health Insurance Quote Form

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. Information submitted will be held confidential and will be used for quote purposes only.

Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Personal Information *Indicates a required field
*Full name:
*E-mail:
*Daytime phone:
Evening phone:
Fax:
How would you prefer to be contacted regarding your quote?	Phone Fax Mail Email
If you prefer to be contacted via phone, please let us know the best time to call.	AM PM
Address:

City:
State:
*Zip:
County:

Requestor's Information Applicant
Gender:		Male Female
Date of birth:		mm/dd/yyyy
Height:		ft. in.
Weight:		lbs.
Smoked in last 12 months?		Yes No
High blood pressure? (Under control or not.)		Yes No
Currently employed?		Yes No
Spouse (if applicable)
Gender:		Male Female
Date of birth:		mm/dd/yyyy
Height:		ft. in.
Weight:		lbs.
Smoked in last 12 months?		Yes No
High blood pressure? (Under control or not.)		Yes No
Currently employed?		Yes No
Major illnesses Within the past 10 years, have you or anyone to be covered received medical or surgical consultation, advice, or treatment, including medication for any of the following: Stroke Heart or circulatory system disorders Liver disorders Kidney diseases Emphysema Rheumatoid arthritis Ulcerative colitis Diabetes Cancer Alcohol/Drug abuse Immune system disorders, including HIV infection Tested positive for HIV infection
Yes No
Please list all current medications for anyone to be covered:

Current Insurance Status
Has ANY PERSON to be covered lived in the U.S. for LESS than 12 months?		Yes No Note: "No" means that all persons to be covered have lived in the U.S. for over 12 months.
Are you currently insured?		Yes No If "No," please continue to Coverage Options section.
If "Yes":
Current insurance company:
Policy renewal date:		mm/dd/yyyy
Group or Individual coverage?		Group Individual

Coverage Options
Dependent coverage required?
Number of children:
Ages of children:		Separate with commas, e.g. 8, 12, 14
Maternity coverage? Note: Maternity coverage is mandatory in some states, so if you are female, of child-bearing age, and not sure if you need this coverage, check "Yes."		Yes No
Is applicant or spouse currently pregnant?		Yes No
Optional Coverages Please select any options you would like included in the quote.		Co-payments Prescription Card Vision Care Wellness Coverage Dental
Optional coverage comments:
Additional comments:

Phillip R Davis & Associates

Ashley Gibney

Melanie Littell

Nancy Nap

Michelle Clark

Individual & Family Health Insurance Quote Form

Personal Information

Requestor's Information

Applicant

Spouse (if applicable)

Major illnesses

Current Insurance Status

If "Yes":

Coverage Options