Consumer Directed Employee Benefit Solutions
BBB Accredited Business
  
Call us : 901-219-8835
Email : marlin@cdbsagency.com
 
   
 
   
 
General Information
Name:
Address:
City:
State:     Zip:
Phone:
Best Time To Call:   AM   PM
E-mail Address:
Date of Birth:
height :
Weight :
Do you smoke tobacco or use tobacco products : Yes
No
Do you want coverage for a spouse and/or children Yes
No
For dependent coverage please enter their information below
What date do you want your coverage to begin?

 

Date of Birth

Sex

height

Weight

Tobacco Use

Applicant

MF

Spouse

MF

Child 1

MF

Child 2

MF

Child 3

MF

Child 4

MF

Child 5

MF


Medical History Questions
Do you or any applicant for coverage have major medical insurance in force that will not terminate prior to the coverage you are applying for taking effect Yes
No
If you are currently insured, when will that coverage expire?
Are you or any of your eligible dependents currently pregnant ? Yes
No
Have you, or any person to be covered, been declined insurance due to health reasons Yes
No
In the past 5 years, have you, or any person to be covered, received any treatment, medication, or surgical advice for; heart or circulatory system disorders (including heart attack or chest pain), stroke, diabetes, cancer or tumor, leukemia or any blood disorder, alcohol or drug abuse or dependence, immune system disorder or tested positive for exposure to HIV or been diagnosed as having ARC or AIDS caused by HIV infection or other sickness or condition derived from such infection Yes
No


Current Individual Health Insurance Information
Carrier (Company) Name (not agency):
Policy Expiration Date: Premium Amount: $
Years Insured:
Please give a brief description of your current health plan, if applicable:

Benefits Desired
Major Medical
Deductible: 		Optional
Pregnancy Coverage: 		Yes
No
Dental Coverage: Yes
No		 Supplemental
Accident Coverage: 		Yes
No
Disability Insurance: Yes
No		 Health Savings Health Savings Acct Plan : Yes
No
Life
Insurance:
 Yes
No		 Life Ins. Amount: $

 

      


Existing Health Problems

Any health problems that could affect premium? Please explain.


Additional Comments or Questions

Please click the "Submit Quote" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.

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