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Health Plus Consulting Services, Inc.
7922 Summa Ave. Suite A2 · Baton Rouge, LA 70809 · Phone: 225-612-2323 *
Fax: 225-612-2324
2322 N. Arnoult Rd. Suite 200 · Metairie, LA 70001 · Phone:
504-835-2124 * Fax: 504-835-2195
REQUEST FOR INDIVIDUAL QUOTE
Name ______________________________________ Requested Effective Date
____________
Phone: ___________________ Cell:
________________ Fax: _________________________
Address ______________________________ City __________________ State __ Zip
______
Age _____ Weight _____ Current Carrier
__________________________________________
Dependants Name/Age/Weight (If
any)______________________________________________
_____________________________________________________________________________
Current Benefits
________________________________________________________________
1. Did you or your dependents incur medical expenses of $5,000 or more during the last 12-month
period?
YES _______ NO ________
2. Please circle the type of plan you are interested? (circle
one) PPO
HMO Unsure
3. Do you or your dependants currently have serious health problems? (For example, but not limited to: cancer, heart trouble, neuromuscular disorder, AIDS, kidney trouble, paralysis or diabetes)
YES ______ NO _______
4. Is there an active maternity case? YES _________ NO __________
5. Are you or your dependants on disability or on waiver of premium status? YES
___ NO ___
6. If the answer to any of the above is YES, please give details including:
NAME: ____________________________________________________________________
Health Conditions (Dates)/Type of Treatment and Charges:
______________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________ ____________________________
____________
Name of Individual
Signature of Individual Date
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