[vc_column_text pb_margin_bottom=”no” pb_border_bottom=”no” width=”1/1″ el_position=”first last”] Coverage Needed Insured Information Spouse Info Children Medical History Instructions Fill out the form below as completely as possible. An Empower agent will then contact you with the lowest possible price based on the information you provide. Coverage Needed Individual Health Short-Term Medical Dental Disability Long-Term Care CONTINUE > Insured Information First Name (required) Last Name (required) Email Street Address Apartment/Suite # City State —Please choose an option—AKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVIVAWAWVWIWY Zip Home Phone Work Phone ...Ext. Fax Number Sex FemaleMale Date of Birth Age Height ft. in. Weight lb. Occupation Employer's Phone Employer's Fax Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo < BACK | CONTINUE > Spouse Information Will your spouse need coverage? noyes First Name (required) Last Name (required) Sex —Please choose an option—FemaleMale Date of Birth Age Height ft. in. Weight lb. Occupation Employer's Phone Employer's Fax Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo < BACK | CONTINUE > Children Information How many of your children will need coverage? 012345678910 Child #1 First Name Last Name Sex —Please choose an option—FemaleMale Date of Birth Age Height ft. in. Weight lb. Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo Child #2 First Name Last Name Sex —Please choose an option—FemaleMale Date of Birth Age Height ft. in. Weight lb. Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo Child #3 First Name Last Name Sex —Please choose an option—FemaleMale Date of Birth Age Height ft. in. Weight lb. Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo Child #4 First Name Last Name Sex —Please choose an option—FemaleMale Date of Birth Age Height ft. in. Weight lb. Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo Child #5 First Name Last Name Sex —Please choose an option—FemaleMale Date of Birth Age Height ft. in. Weight lb. Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo Child #6 First Name Last Name Sex —Please choose an option—FemaleMale Date of Birth Age Height ft. in. Weight lb. Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo Child #7 First Name Last Name Sex —Please choose an option—FemaleMale Date of Birth Age Height ft. in. Weight lb. Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo Child #8 First Name Last Name Sex —Please choose an option—FemaleMale Date of Birth Age Height ft. in. Weight lb. Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo Child #9 First Name Last Name Sex —Please choose an option—FemaleMale Date of Birth Age Height ft. in. Weight lb. Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo Child #10 First Name Last Name Sex —Please choose an option—FemaleMale Date of Birth Age Height ft. in. Weight lb. Do you use other tobacco products? —Please choose an option—YesNo Are you a smoker? —Please choose an option—YesNo < BACK | CONTINUE > Medical History If you have or have had any of the conditions listed below, please select that condition and to the right give a brief history and list treatments. Heart Circulation Problems/HBP/Stroke Lung disorder/Asthma Cancer (inc. skin) Diabetes: diet control/oral meds/insulin AIDS/ARC Mental/Nervous/A.D.D Alcohol/Drug disorder Medical expense of $5000+ in the last year Pregnancy/Disability Hazardous hobbies (ie flying, skydiving) Auto/Boat/Motorcycle/Dirt-bike racing Mountain-climbing/Scuba Diving/Other List any current medications Sales Agent Name Agent Email Agent Phone Please verify that all the information you have entered is correct. Then click the Submit Quote Info button to send us your request for a quote By checking this box, you consent to receive text messages from Empower Brokerage and/or a licensed Empower Brokerage agent. These messages may include marketing messages (e.g., promotions, reminders) and follow-up communications related to your inquiry to the number provided, which may include the use of an autodialer. Message and data rates may apply. Message frequency varies. You can unsubscribe at any time by replying STOP or clicking the unsubscribe link. By clicking and submitting this form with my name, phone number, and e-mail address, I agree that I am at least 18 years of age. By clicking and submitting this form, I understand that I am enrolling in an ongoing marketing campaign about insurance services and other options from Empower Brokerage or a licensed agent, and I will receive phone calls and e-mails (even if that phone number is on any Do Not Call Registry or is a mobile number). If you want to opt out of receiving future e-mails from Empower Brokerage, you can do so at any time by clicking the “unsubscribe” button in our e-mail. 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