Why do you need health insurance? Getting sick or injured is bad enough without having to worry about how you'll pay for the care you receive. Without the proper health insurance coverage, a major illness or injury could spell financial disaster for you or your family. Purchasing a health insurance policy may help protect against an unpredictable financial loss.

Here's an example of how health insurance pays off. If you accumulate $60,000 in medical expenses as a result of a serious illness without health insurance, you are responsible for the entire amount; with insurance, your out-of-pocket responsibility might be reduced to just $5,000 - your annual deductible and coinsurance.

Can you afford not to have adequate health insurance coverage? Call me today to see which health insurance plan would be best for you.

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Contact Information
Name:
Address:
City:
State:	State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code:
Day Phone:
Night Phone:
Fax:
E-Mail:
Contact me during?	Morning Afternoon Evening
Occupation
Any Current Medications or Health Challenges?
Is any proposed Insured or family member an expectant parent or currently pregnant? Yes    No

Policy Holder
Date of Birth
Gender	M/F
Smoker	Y/N
Medications, Dosage, Frequency
Ht
Wt
Spouse
Date of Birth
Gender	M/F
Smoker	Y/N
Medications, Dosage, Frequency
Ht
Wt
Child # 1
Date of Birth
Gender	M/F
Medications, Dosage, Frequency
Ht
Wt
Child #2
Date of Birth
Gender	M/F
Medications, Dosage, Frequency
Ht
Wt
Child #3
Date of Birth
Gender	M/F
Medications, Dosage, Frequency
Ht
Wt
Child #4
Date of Birth
Gender	M/F
Medications, Dosage, Frequency
Ht
Wt
Health Options
HMO  PPO   MSA
Deductible
250 500     1000
Co-Payment
10   15       20      No Co-Payment
Is Maternity Coverage Important?  Yes  No