To better service your needs, please let us know the types of coverage you are interested in:

Individual Medical/Medical Savings Account

Individual Life/ADD

Individual Disability

Long-Term Care (complete only General Information section and an agent will contact you)

General Information

Name
Address
City
State ZIP
Day Phone
Eve Phone
Fax
Email

To receive a quote for medical insurance, please complete the following information:

Your Name
Date of Birth (mmddyyyy) Gender: M F
Do you use any form of tobacco? Yes No
Height Weight

Spouse's Name
Date of Birth (mmddyyyy) Gender: M F
Do you use any form of tobacco? Yes No
Height Weight

Child's Name
Date of Birth (mmddyyyy) Gender: M F

Child's Name
Date of Birth (mmddyyyy) Gender: M F

Child's Name
Date of Birth (mmddyyyy) Gender: M F

Child's Name
Date of Birth (mmddyyyy) Gender: M F

Are you, or anyone in your family taking medication? If yes, please describe medication, dosage, how long you have taken medication and the purpose of medications.

Do you or anyone in your family have a pre-existing condition? If yes, please describe.

Do you own a business? Yes No

To receive a quote for disability insurance, please complete the following information:

Your Name
Date of Birth (mmddyyyy) Gender: M F
Do you use tobacco? Yes No
Job Title
Occupation
How long at current job?
Current Annual Salary

To receive a quote for life insurance, please complete the following information:

Your Name
Date of Birth (mmddyyyy) Gender: M F
Do you use any form of tobacco? Yes No
Spouse's Name
Date of Birth (mmddyyyy) Gender: M F
Do you use any form of tobacco? Yes No

Type of Life Insurance Needed Select One Universal Life Whole Life Variable Universal Life Term Not Sure

If requesting term coverage, please select period Select One 10 years 15 years 20 years 30 years

Coverage ammount for you
Coverage ammount for spouse

Purpose of insurance

How did you hear about us?

Comments/Other

Thank you for your interest in Hofgard & Company!