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Ziemann Insurance Services, Inc.
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INDIVIDUAL AND GROUP HEALTH INSURANCE
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YOU CAN GO DIRECTLY TO ONE OF THE FOLLOWING SITES, REVIEW THE BENEFITS AND COMPLETE YOUR APPLICATION. A WORD OF CAUTION: YOU MIGHT WANT TO CALL ME FIRST 480-451-1500 TO DISCUSS YOUR HEALTH HISTORY. IF YOU ARE DENIED COVERAGE WITH ONE CARRIER IT MIGHT NOT BE POSSIBLE TO GET COVERAGE WITH ANY OTHER CARRIER.
THE RATES ARE THE SAME WITH OR WITHOUT A BROKER! A GOOD BROKER CAN SAVE YOU TIME, KEEP YOU INFORMED OF CHANGES AND ASSIST YOU WHEN YOU NEED EXTRA HELP.
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Print this form first and complete. Please fax or e-mail the following information:
Name:_____________________________________________________
Address:__________________________________________________
__________________________________________________________
__________________________________________________________
Phone:____________________________Fax:____________________
E-Mail:_____________________________________________
Birthdate:________________________________Height/Weight:_____/_______
Current Coverage:_________________________________________
Dependents to be covered (provide birthdate, hgt/wgt, gender)
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Please give pertinent medical information to cover the past 10 years for all those to be covered. Provide as many details as possible including medications.
__________________________________________________________
__________________________________________________________
__________________________________________________________
IF THERE IS SIGNIFICANT MEDICAL INFORMATION, PLEASE USE THE MEDICAL ASSESSMENT FORM FOUND ON GROUP HEALTH LINK PAGE 2. AGAIN, YOU CANNOT COMPLETE THE FORM ON LINE. PLEASE PRINT FORM AND THEN FAX TO ME.
PREMIUM RATES ARE THE SAME WHETHER YOU USE AN AGENT OR GO DIRECT TO THE CARRIERS. AGENTS (GOOD AGENTS) OFFER MANY ADDITIONAL SERVICES THAT WILL SAVE YOU TIME AND EFFORT.
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