If you have any questions, please call (818) 654-4548  
 
Health Insurance Quote
SELECTING A PLAN TYPE:
Use the statements below to help determine what plan type best meets your coverage needs.
 

I want more control over my health care and access to any doctor
or specialist I choose.

 PPO PLAN

I need a lower monthly premium so I'm willing to pay more for my
health care services as they occur throughout the year.

 PPO PLAN

I want to pay as little as possible when I see a doctor, so I'm willing
to select a specific medical group and physician to coordinate all of
my health care needs..

 HMO PLAN

I'm willing to pay a higher premium up front so that my costs for health
care services are lower as the occur throughout the year.

 HMO PLAN

We will compare and pick the best plan for you !
*Type of Health Insurance:

 
*Health Plan Choice:
* Dental Plan Choice:
   
  Your Contact Information - Required ( * )  
 
*Your Full Name  
*Address 
*City 
*Zipcode  *State 
*Email address 
* Home Phone 
* Work Phone     Ext.

Health Information
* Age 
    
*Gender 
Male   Female
* Height 
'    " * Wt      * Smoker 

Optional Health Information about Spouse:
 
First Name M.I. Last Name
Age
Gender
Male   Female
Height:
'    " Wt:    Smoker:

Child Information (Optional)
          Gender                  Age
Child
           
Second Child
           
Third Child
           
Fourth Child
           

Additional Information
Has any person to be covered lived in the USA for less than 12 months?
Would you also be interested in a FREE quote for Annuity products?
Would you also be interested in a FREE quote for Life Insurance products?

*Preferred Contact Time:

Comments [Critical Information]
 

an Agent will contact you
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Copyright © 2005 Oleg Skurskiy Authorized Independent Agent, CA License 0E50389