Need quote MIchigan health life insurance policies

Michigan Health and Life Group LLC

Affordable Insurance for Individuals, Families and Business

Health & Life Insurance, Disability, and Accident

Please complete the information below to request a quote.
Michigan Health and Life Group does respect your privacy. All the information submitted will be kept in strict confidence. The submitted information will not be used for any other reason than to aid us in the quoting process. You will receive a call from us to help you obtain the best plan at the most affordable rate.

Quote Request

Please provide as much information as possible for an accurate quote.

Name (first/last):
Contact Ph#:
Email Address:
Your Home Zip Code:
Height:
Weight (lbs):
Do you smoke?
Current Age
Spouse first name:
Age of spouse:
Height of spouse
Weight:
Does spouse smoke?
Child #1 Age:
Sex of child:
Child #2 Age:
Sex of child:
Child #3 Age:
Sex of child:
Child #4 Age:
Sex of child:
Child #5 Age:
Sex of child:
Is anyone included in this quote pregnant?:
Has anyone been treated by a doctor for a major health condition in the past year? *:
Has anyone been hospitalized in the past 5 years (excluding pregnancy)?:
Has anyone been denied coverage in the past year?:
Do you currently have health insurance?:
Who is your current carrier?:
Does anyone take prescription medications?
Please list the prescription medications and what person is taking them.
Does anyone have any major ongoing health conditions?:
Please select any health conditions that apply::
Alcohol / Drug Abuse		AIDS / HIV
Asthma		Alzheimer's / Dementia
Cancer		Clinical Depression
Diabetes		Emphysema
Epilepsy		Heart Attack
Heart Disease		Hepatitis/Liver
High Blood Pressure		High Cholesterol
Kidney Disease		Mental Illness
Multiple Sclerosis		Pulmonary Disease
Stroke		Ulcers
Vascular Disease
Please provide any further information regarding any items that have been checked i.e. which person, how long since diagnosed, etc.:

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