Alaskan Benefit Insurance Consultants

1) Name (required)

2) Address (required)

3) City (required)

4) State (required)
Alaska

5) Zip Code (required)

6) Phone (required)

7) Fax

8) E-mail Address (required)

9) Sex (required)
 M F

10) Smoke (required)
 Yes No

11) DOBMM-DD-YY (required)

12) Height & Weight: (required)

14) Major Health Conditions or medications for all family members?: (required)

15) Spouse Info:
 M F

16) DOBMM-DD-YY

17) Smoke
 Yes No

18) Height #'& #":

19) Weight:

20) Children DOB'S MONTH / YEAR, SEX M/F:

21) Deductible:
 500 to 5,000  1,000 to 25,000  Variety of choices  HSA DEDUCTIBLES

22) Desired Effective Date MM/YEAR: (required)

23) Type of Insurance Desired: Check all that apply.(required)
 Health Savings Account HSA  Maternity  Dental  Vision  Disability  Life  Supplemental Accident Long Term Care  Medicare Supplement  International Health Plans  HEALTH INSURANCE Annuity  Short Term Coverage

24) Are you interested in a Medicare Supplement Plan Letter?
 Yes No

25)  Medicare Supplement Plan Letter

26)  Short Term Coverage
# Months