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Request Individual Health Proposal

Our general proposal practices:

Please complete this form and submit. Our staff will work diligently to return by E mail a preliminary rate for the benefits selected within three business days. If the rates and benefits are desirable, you may simply reply to our E mail and we will forward a full proposal, insurance company information, and an enrollment package so that you may make a quality decision.

If you need help completing this form, please call: (501)312-4607 or (888)236-7242 (Toll Free) or e-mail: marketing@aiba.com.


Name: REQUIRED
Telephone: REQUIRED
E-mail Address: REQUIRED
Address: REQUIRED
City: State: Zip:REQUIRED
Occupation: REQUIRED

Information about your current benefit plan or type of benefits you desire:

In Network Out of Network
Deductible
Coinsurance Level
Maximum Out-of-Pocket
Office Visit Co-Pay N/A

Do you currently have coverage ?:   Yes  No

If Yes, Current Monthly Premium:

Please provide a brief statement indicating the reason that you are looking for a new insurance carrier

Please provide the following data for each person who will be covered:

  Age or D.O.B Sex:
Primary Male Female
Spouse Male Female
Child 1 Male Female
Child 2 Male Female
Child 3 Male Female
Child 4 Male Female
Child 5 Male Female
Child 6 Male Female

Have any of the proposed applicants listed had any of the following conditions during the past 5 years ?

High Blood Pressure:  Yes No
Diabetes: Yes No
Cancer: Yes No
Heart Attack or Bypass: Yes No
Stroke: Yes No

Do any of the proposed applicants have any type of health condition
that might affect insurability ?  Yes No

If you answered YES to any of the above questions, please describe the condition, treatments, hospitalization, and any drugs that are currently being taken.

All Information provided will be used soley for providing a health proposal and will be discarded within 30 days of providing a proposal.


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