Set Appointment Form

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Let Us Help You Choose a Plan

Fill out the telephone appointment request form below - this will give our advisors the information they need to do an initial analysis of all available plans, so that they can better discuss the best options for your needs. During the meeting we will review your options, you'll learn the pros and cons of the plans you are considering, and you will be able to confidently choose the plan that's right for you.
Once we receive and review the information you send, someone from our office will call you to schedule a time for you to speak with one of our Personal Advisors.
Please note: ALL information must be filled out completely before we can schedule an appointment. As soon as we receive your proposal request, we will let you know available phone consultation times.

All information will be kept confidential, and is requested solely for the purpose of providing you accurate advice (see our Privacy Statement).

Contact Information (* Required)

First Name: *

Last Name: *

Email: *

Phone: *

Street Address: *

City: *

State: *

* Plans are only available in the listed states.

Zip Code: *

Date of Birth: *

Insurance Information

Primary:*

Sex	Smoker?	Height	Weight

Current Insurance Information:*

	Insurance Comp:
	Monthly Premium:
	Deductible:

Additional Family
Members:

Sex	DOB	Smoker?	Height	Weight

Is any family member currently pregnant?
(Plans cannot be written until after the baby is born. When is the due date?):

What Type of Plan are you looking for?
(HSA, CoPay, Low Cost, ECT)

Please say if you have a specific plan in mind.

Do you have a general idea of what type of coverage you are interested in? For example, are you looking for a plan that qualifies to work with a Health Savings Account, or a traditional plan with co-payments for doctor visits and prescriptions, or perhaps a low-cost basic plan that provides you with catastrophic coverage?

Does anyone that will be applying for coverage have diabetes, heart disease, or any other pre-existing medical conditions?

Is anyone currently taking medication?
(If so, what is the reason,
and what is the medication?)

When would you want your new plan to become effective?

Have you reviewed your instant quotes (Y/N):

Instant Quote Engine

If NO: If you have internet access, we recommend that you take a moment to review your instant online quotes, which are available at www.eAZHealthinsurance.com. This will give you a general idea of what is available, and will help to ensure that you make the most of your time.

Comments:

Who referred you to
eAZHealthInsurance ?

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