Medical Links Long-Term Care Links
Individual Coverage Quote Form
To receive a free quote for Individual Medical, Life, Disability and Long-Term Care Insurance, please complete the following form or call us at 303-442-1000 or 800-887-0054.
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
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!
1510 28th Street, Suite 250 - Boulder, CO 80303 p 303-442-1000 | 800-887-0054 | f 303-449-0243 | Contact Us © 2006 Hofgard & Company | Privacy Statement