American Risk and Insurance Associates, Inc.

Please take the time to fill out the following information so we can provide you with a free, no obligation insurance quote. Please provide as much information for the most accurate quote. This information is confidential and will be used for quote purposes ONLY.

You will be contacted by e-mail, fax or phone within 24 hours of submission of online questionnaire.
No coverage is bound by this submission.

Basic Information *Required information

First name*

Last name*

Address *

City*

State*

Zip*

Marital Status

Best way to be contacted?*

Phone number (add area code)*

Best time to call*

Fax number

Work number

E-mail address *

Occupation

How long

Additional Comments:

Personal Information

Marital status

Gender

Date of Birth (mm/dd/yyyy)

Weight:

pounds

Your height

Please describe your occupation

Smoker

I used to smoke, but quit:

# of children to be covered

Are you now or have you been insured within the past 30 days?

Current insurance carrier (if insured) How long years months

Policy expires

Do you have any of the following medical conditions?

IF you answered "OTHER" please explain:

Are you currently under the care of a physician or taking medication for any condition or
disease? If YES, please provide a brief description of the condition:
:

Additional Information:

Spouse Information (if needed)

Name

Gender

Age

Smoker

DOB (mm/dd/yyyy)

Height

Weight

lbs

Occupation

# of children to be covered

Are you now or have you been insured within the past 30 days?

Current insurance carrier (if insured) How long years

Policy expires

Do you have any of the following medical conditions?

IF you answered "OTHER" please explain:

Are you currently under the care of a physician or taking medication for any condition or
disease? If YES, please provide a brief description of the condition:
:

Health Plans and Options

Select Plan and Options you would like to receive:

Plans:

Options:

PPO (Preferred Provider Organization) - This flexible plan affords you the ability to choose any doctor or hospital form the PPO's directory or to use a doctor outside the plan at a higher expense.

POS (Point of Service) - This plan allows you to choose the level of benefits received. By coordination with a Primary Care Physician you'll receive a higher level of benefits. This plan also allows your to choose any doctor or hospital and receive a lower level of benefits.

Major Medical - This plan is favored by those who prefer to choose any doctor or hospital. This is the most unrestricted plan. Consumers are responsible to pay in full in advance for medical services they receive and file their own claims paperwork to seek reimbursement.

Additional questions or comments?

Quotes are based on information provided, which will be verified before acceptance.
Acceptance is based upon your continuing qualification. Individual savings may vary.
Additional information may be needed to provide accurate quote.