Direct Choice Insurance | Commercial Application

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In just minutes, you can compare quality health insurance quotes to find the one that's right for you

Step 1 - Medical Profile Information

	Gender	Date of Birth	Height	Weight	Smoker
Applicant

Do you have a spouse who needs insurance?	Yes	No
Number of children
Are any applicants expecting a child?:	Yes	No
Are you currently insured?:	Yes	No

Does anyone listed above have any of these conditions? (Check all that apply)

AIDS/HIV	Alcohol/Drug Abuse	Alzheimer's Disease	Cancer
Depression	Diabetes	Heart Disease	Kidney Disease
Liver Disease	Mental illness	Pulmonary Disease	Stroke
Vascular Disease

Step 1 -Contact Information

First Name	Last Name
Street Address	Apt or Unit
City	State
Zip Code	Daytime Phone	Ext:
Evening Phone	Email

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By clicking submit and seeking a quote request i authorize and agree that up to five insurance companies of their agents and Direct Choice partners may contact me using this information or to obtain additional information needed to provide quotes where permitted by law. These partners may include top health insurance companies such as Aetna. American Republic, Anthem, Assurant Health, Bankers, Blue Cross Blue Shield, CIGNA, Golden Rule, Health Markets, Humana, Kaiser Permanente, United Healthcare and WellPoint, I acknowledge that I have read and understand all of the Direct Choice Terms and Conditions and agree to be bound by them