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Individual Health Insurance Online Quote

All fields marked with an asterisk (*) are required to complete the form. However, please complete as many fields as possible to ensure that we can prepare your quote as soon as possible.

Please note that Keystone Insurers Group cannot guarantee the security of any information you submit through these forms. If you feel uncomfortable submitting personal information over the Internet, but wish to learn more about our company, products or services, please give us a call at 814-781-7234.


About Yourself

* Name:

* Email Address:

* Address 1:

* Address 2:

* City:

* State:

* Zip Code:

* Phone (Day):

Phone (Evening):

Fax:

* Date of Birth (mm/dd/yyyy):

* Gender:

* Social Security Number

 

Spouse and Children

Will your spouse be covered?:

 Yes No

Enter your spouse's birthdate (mm/dd/yyyy):

Will your children be covered?:

 Yes No

Enter number of children:
 

Medical History

1. Do you or any applicant to be insured have any hospital, major medical, group health, government or medical insurance coverage in force that will not terminate prior to the effective date of this coverage?

Yes

No

NOTE: If you answered 'NO' to this question, you do not need to complete question 'a' below. Go on to question 2.

a) When will existing coverage expire? (must be within the next 30 days) (mm/dd/yyyy):

2. Are you, your spouse, or any dependent, (whether listed on the application or not) now pregnant or are you an expectant father of any unborn child?
Yes
No

3. Have you, or any person to be insured been declined for insurance due to health reasons?
Yes
 No

4. Have you or any applicant to be insured in the past five years received any treatment, medication, or medical or surgical advice for heart or circulatory system disorder, including heart attack or chest pain, stroke, diabetes, cancer or tumor, leukemia or any blood disorder, alcohol or drug abuse or dependency, immune system disorder or been tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection?

Yes

 No
 

Details

Any comments or question?