Agent Request Form
Privacy Statement
Agent Information
Agent Name:
Date:
Email:
Phone #:
Client Information:
Client's Name:
R
equested Effective Date
:
Email:
Phone Number:
ZipCode:
Age
Gender
Ht
Wt
Applicants Name
M
F
Non-Tobacco
Tobacco user
M
F
Non-Tobacco
Tobacco user
M
F
M
F
M
F
Had insurance within the last 63 days?
Select
Yes
No
Employment Status:
Select
Self Employed
Employed - Group Plan Available
Employed - Group Plan Not Available
Laid off
Unemployed
Disabled
In School
Currently have health insurance?
No Insurance
COBRA
TennCare
Aetna Ind
Aetna Group
BCBST Individual
BCBSTGroup
UnitedHealth Ind
UnitedHealth Group
Cigna Individual
Cigna Group
Humana Individual
Humana Group
Farm Bureau / TRH
NASE/Mega Life
Midwest of Tennessee
Other
Other Group Insurance
Non-Insurance Discount Card
Select
Yes
No
Been offered COBRA Insurance?
Reason needing insurance:
Select
Losing COBRA
Don't have insurance now.
Looking for better rates
Loosing Group Coverage
Needing policy for child only
Family coverage on Group Plan too expensive
Needing coverage to help pay for medication
Other
Select
Yes
No
Been declined for Insurance?
Medical Information
Please list medical conditions and prescriptions currently taking such as High Blood Pressure, Diabetes, Heart Conditions,
Allergies, Depression (This will allow us to get you a more accurate report)
Family Member
Diagnosis/Condition
Medication
Details
Primary Applicant
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Primary Applicant
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Primary Applicant
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Primary Applicant
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Primary Applicant
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Additional Information
Describe unique situation that may affect c
lient
being able to obtain coverage. If there is a maximum budget, list here.
By submitting this form, you are requesting Tennessee Health Insurance Services to provide a quote to the
prospect
ive client
. This is not an application for medical insurance. Any offer of insurance will require completion of
an medical application for the respective insurance carrier.
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TennHealth Insurance Services
210 Hidden Hills Cir
Lexington TN 38351