Affinity Insurance Agency, Inc.
Health Insurance Indication Form
HEALTH INSURANCE INDICATION FORM
Name:
Address:
Email:
City:
State:
Zip:
County :
Phone:
Fax:
Please circle option that applies:
Individual & Family
Small Business
Applicant
Gender
Date of Birth
Tobacco use last 12 months
Full Time College Student
Please circle Optional Features:
Maternity
Disability Income
Dental
Accident Plan
Vision
Cancer
Long Term Care
Specified Health Event
Current Effective Date:
Requested Effective Date :
Comments:
Phone: 770-974-5502
Fax: 770-974-5359
Mail: mklocke@profliability.com
3950 Cobb Parkway, Suite 707
Acworth, GA 30101