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 GROUP HEALTH PLANS OF LA

We provide you with a free, no-obligation  health insurance quote.  Your personal health history is very important in getting a quote that matches up with reality,  one that you will be able to obtain.. Questions...Send E-mail

 Please fill out the form below for individual quote requests.
 E-mail address and daytime phone number are required entries.
   (We do not resell information to anyone for any purpose)

 (Businesses with 3+ employees that wish to assist employees with
  college savings plans or long term care coverages may...........    Click Here! 

Please call or send me more information about:

Ways to save for college
 Tax deferred Savings Accounts

Universal Life Insurance
 Educational Ira

Please fill in completely, the information below:
I live in Louisiana    I live in another state     (Name, email address, zip code & county/parish are required)
My  Age:            Male/Female        Smoker Height :           Weight: lbs. 
Spouse: Age:      Male/Female        Smoker Dependents: ->  #        Ages
Name:         Occupation:        
Address:     City, State, Zip:    
 E-mail: Required * Parish/ County 

Office Phone:     Fax:  
Home Phone:     Area Code         		Best time to call 
Own your own business? No Yes   
 
Your health history is always helpful   (we do not resell information to anyone for any purpose)

Do you have health conditions? YesNo   -------  Please Detail yes answer below
 Diagnosis?           Chronic?        Date of onset:        Treatment or Surgery required?      Is this covered currently?

Prescription medications?YesNo   Explain: Yes,.....   Rx name          (mgs?)       (x per day)

Engage in hazardous activities? (i.e. scuba,skydiving,private pilot,etc.)YesNo   If Yes,  Please Explain:

 
Current method of saving for college costs?          

Want a Life insurance quote?             Term  Cash Value Final Needs Buy-Sell Agreements Other Ins.
                                                                  
Want a Disability Insurance Quote?  Income   Title:    Job Duties:


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