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    Your Name:
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    E-Mail again for accuracy:
    Phone (if more info. needed):
    Fax (optional):
     
    Marital Status:
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    		Gender:
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    Type of Health Insurance
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    UNDERWRITING INFORMATION
     
    Insured Name: Birthdate:
    Insured Height: Insured Weight:
    Spouse's Name: Spouse's Birthdate:
    Spouse's Height: Spouse's Weight: (M/F):
     
    Include Spouse?: Yes No Include    
    Children?:    		 Yes No
     
    List children's names,
    (first & last), their
    relationship to you,
    and birthdates:
    (up to 6 children)    		 Name/Rel.:B-Date: M/F:
    Name/Rel.:B-Date: M/F:
    Name/Rel.:B-Date: M/F:
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    Name/Rel.:B-Date: M/F:
    Name/Rel.:B-Date: M/F:
     
    Be as specific as you can on the underwriting questions below so we may find the most competitive product for you!

    Does any family member living in the household use or has used any tobacco products? (if yes give dates, and details in remarks section).
    Yes   No

    Describe usage (cigar,
    cigarettes, etc, and how long.)          

     
    Any Pre-existing Health Conditions?
    		 (If yes, descibe in detail, and to which of the insured persons they apply.)
     
    Any Covered Persons Currently Taking Medication of Any Kind?
    		 (If yes, descibe in detail, and to which of the insured persons they apply.)

    COVERAGE INFORMATION
     
    Are You Looking for Coverage for more than 6 months?
     
    What Deductible Are You Interested In?
    ($250, $500, $1000, $2000 etc.):
     
    Any special coverages needed?
    (Maternity, H.M.O., P.P.O., etc.)
     
    If you're looking to reduce premium cost, and want information on the NEW HSA (Health Savings Plans), check the HSA box here and we'll include information. Please Include HSA Information
     
    Tell Us What You Want MOST in your Health Plan, or list any other Remarks here:

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    Bromberg Insurance Services, Inc. | Email: Info@BrombergInsurance.com | About Us
    12327 Santa Monica Blvd., Suite 102 - Los Angeles, CA 90025 | CA Insurance Lic# OB74374
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