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SHORT TERM MEDICAL INSURANCE QUOTE
Please fill out the following form to the best of your ability in order for Insurewiz provide you with a quote for short-term medical insurance.  We will find a competitive short term medical insurance plan for your in your state of residence.
Full Name
Mailing Address
City
State
Zip Code
Country
Daytime Phone
Extension
Fax
Email
Best time/day to call
Date of Birth
Male or Female
Names, relationship, and  birthdates of dependents  to be covered  
Occupation  
Smoker  
Height   
Weight   
Have you ever been declined for Medical Coverage due to health conditions?
Medical Conditions
Select all that apply by holding down the "Ctrl" button and clicking on each condition that you have been treated for.
Claims exceeding $1,000 during last 12 months
(diagnosis, current status)
Annual Deductible Desired
Coinsurance Level Desired
For how long will you need coverage?
Do you currently have group or individual health insurance?
Do you currently have short term medical coverage?
If you currently have coverage, list the company that you currently have coverage with.
If you are looking to change companies, what is your reason(s) for changing?
How soon would you like to enroll for coverage?
How much are you budgeting to spend per month for this insurance?

InsureWiz Quotation Policy  After filling out the necessary information on this form you will receive a quote via phone or email and then have the option of applying for the actual overage. There is no commitment for filling out the information on this form and receiving a quote.  An InsureWiz representative can assist you in completing this form.  
 

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