Associated Insurance Centers - Medical Insurance

	of Sussex, Wisconsin 262.246.6868 jimstein@associnscenter.com (licensed in Wisconsin, Illinois, Michigan & Minnesota)
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Medical Insurance

Major Medical - Permanent or Short Term

So, you want "some good health insurance". We need to get some details about the plan you have or are interested in, because it will only be as "good" as your first/next claim for coverage. And, when you file a claim is the worst time to find out how "good" it is. So, what do you have/want?

Contact information
Please complete the follow information so we can contact you with the information you requested.

First Name Last Name Middle

Address City State Zip

Phone Best time to call: E-Mail

About Your Medical Needs Fill in as much or as little as you please, we will call to better understand your needs
Current insurance expires or Check here if you Currently Have No Insurance
What type of insurance fits your preference?
Plan A: (Higher Priced) $35 Office Co-Pay with $500 In-Patient Deductible; $1,000 In-Patient Deductible $45 Office Co-Pay with 500 In-Patient Deductible; $1,000 In-Patient Deductible Co-insurance 80%-20% 70%-30% 60%-40% PPO non-PPO
Other combinations available - describe yours:
Plan B: (Less Expensive) High deductibles - $1,000 $1,500 $2,000 higher? Co-insurance - 100% 80% other? PPO Non-PPO
TAX-advantaged: Health Savings Account Low deductible High deductible PPO Non-PPO
Now, A Little More About The Insureds Fill in as much or as little as you please, we will call to better understand your needs
Primary Insured:
First Name Last Name Middle Gender
Date of Birth mm/dd/yy Height Weight
Smoke? Yes No
Describe ANY health problems-
2nd Insured:
Relationship to Insured:
First Name Last Name Middle Gender
Date of Birth mm/dd/yy Height Weight
Smoke? Yes No
Describe ANY health problems-
3rd Insured:
Relationship to Insured:
First Name Last Name Middle Gender
Date of Birth mm/dd/yy Height Weight
Smoke? Yes No
Describe ANY health problems-
Target month
If an employer group plan, note here & e-mail us
Miscellaneous Comments & Requests: