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Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Your Information for Individual Health Insurance Quote:
First Name
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Last Name
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Street Address:
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CITY:
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State:
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ZIP / Postal Code
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E-Mail Address
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PRIMARY PHONE NUMBER:
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Do you currently have a health plan?
Your current health plan, if applicable:
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Please Select Which Type of Plan(s) Considering:
Various types of insurance plans you are interested in:
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Please check as many plan types as you wish to explore:
Single Subscriber
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Single Subscriber with children under age 26
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Subscriber & Spouse only
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Subscriber, spouse and children under age 26
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Please provide following information where applicable:
Your Age
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Spouse Name (If applicable)
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Spouse's age
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Child's Name (if applicable)
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Child's Age
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Child's Name (if applicable)
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Child's Age
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Child's Name (if applicable)
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Child's Age
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Child's Name (if applicable)
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Child's Age
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Comments or Questions:
Please enter your comments or questions here:
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Only for Medicare inquiries:
By completing this form you agree that a licensed insurance agent may contact you by phone or email to answer any questions you have regarding Medicare Advantage, Part D - Prescriptions, or Medicare Supplement plans. This is a solicitation for insurance.
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
   
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400 White Spruce Blvd. Suite C | Rochester, New York 14623
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