Home      Life & Health      Municipal Insurance      Property & Casualty      Personal Insurance      Resources      Links



400 West Main Street
Post Office Box 437
Havana, Illinois 62644-0437

Phone:
(309) 543-6631
(800) 331-0546

Fax:
(309) 543-6607

Click Here to E-Mail Us


Office Hours:
8 a.m. - 5 p.m. (Mon. - Fri.)







A History of the Agency
Health Quick Quote
Contact Information :
1
 first name:
2
 last name:
3
 contact phone:
4
 fax:
5
 e-mail:
6
 address:
7
 city:
8
 state:
9
 zip:
More About You:
10
 your date of birth
11
 your height
12
 your weight
13
 are you a smoker? yes no
if a non-smoker for how long?
Your Spouse:
14
 spouse date of birth
15
 spouse's height
16
 spouse's weight
17
 spouse smoker? yes no
if a non-smoker for how long?
Your Children:
18
 children yes | how many?
19
 child 1 | age | height ft-in | weight lb
20
 child 2 | age | height ft-in | weight lb
21
 child 3 | age | height ft-in | weight lb
22
 child 4 | age | height ft-in | weight lb
Coverage:
23
 requested effective date
24
 any serious health problems
(please explain in detail, include all medications, dosage & who is taking)
25
 deductible requested
Comments or Questions:
26

 When you are finished, press SEND only once. It may take a few moments to process the form. You may also wish to use PRINT, which will open the form in a new window and allow you to print the information for your records or to submit the information in person or via fax.

© 2003-2006 Snedeker Risk Management, Ltd.  All rights reserved.    ·    The Client's Advocate [ www.clientsadvocate.com ]