Full Name:          
Home Address:
State:  Florida
Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You:       Cell Phone:
Date of Birth:              (mm/dd/yyyy)
Gender:    Height:  ft. 
Weight:    Do you smoke?

Do you currently have health insurance?  
Type of health insurance currently owned:
Current Premium:$  per month

Family Health Insurance Coverage For:
Age of Spouse:                                    
How many children to be insured:         

Florida Family or Individual Health Insurance Coverage Desired:

HMO Health Insurance   HMO Co-Pay Amount Desired:  
PPO Health Insurance     PPO Deductible Amount Desired:
POS Health Insurance     POS Co-Pay Amount Desired:    
Major Medical Health Insurance      Deductible Amount Desired:

Choose Benefit Options:
Individual or Family Dental Insurance Coverage:
Individual or Family Vision Insurance Coverage:
Life Insurance Coverage:                                   

Medical Information:

Within the last 10 years have you or any person to be insured been aware of, diagnosed
and /or been treated by a member of the medical profession for: heart disease or
disorder, stroke, cancer, diabetes, drug or alcohol dependency, mental disorder,
emphysema, airway or pulmonary disease, crohn's disease or ulcerative colitis,
nervous system disorder, liver disorder, kidney disorder, crippling or disabling
arthritis, spinal disc disease, knee or hip disorders? 

If "Yes", please list information below.

Have you or any person to be insured been hospitalized
within the past 12 month, due to be so confined or been
disabled for more than 5 days within the past 12 months? 

If "Yes", please list information below.

During the last 10 years have you or any person to be insured been diagnosed by a
member of the medical profession as having Acquired Immune Deficiency Syndrome
(AIDS) or AIDS related complex (ARC) or tested positive for HIV? 

If "Yes", please list information below.

Additional Information or Comments

Click on the "Submit Quote Request" button below to
send your Florida Health Insurance quote request.**

**Information received from this Florida Health Insurance quote request form
sent to Optimal Insurance Group will be for our use only and will not be sold,
given to or distributed to any other parties. A quote will be based on the
Florida health insurance policy information provided and does not guarantee
acceptance of the risk by us. The precise coverage afforded is subject to
meeting underwriting guidelines, and the terms, conditions and exclusions of
the policy as issued. By submitting this request you acknowledge that this is
neither an offer to insure nor a guarantee of insurance. Completion of this form
does not entitle you to a Florida Health Insurance policy. We are licensed
in Florida and will not provide health insurance quotes for other states.

Florida Family or Individual
Health Insurance Quote
We can provide low cost Florida Health Insurance
coverage in the Palm Beach County, Florida area!
Optimal Insurance
Group of Boca Raton,
FL offers affordable and
experienced personal
insurance coverage
services throughout
south Florida.
Contact us about Florida
Health, Auto, Renters,
Homeowners, Boat,
Motorcycle, RV, and
Flood Insurance at
(561) 342-1695.

In addition to low cost
Florida Family Health
Insurance quotes, we
also offer affordable
Homeowners Insurance
policy quotes.
We are an independent Boca Raton, Florida insurance agency offering
low cost health insurance quotes for individuals and families in the
following towns, cities and counties in south Florida: Boynton Beach,
Gulf Stream, Delray Beach, Lantana, Rainbow Lakes, Atlantis, Lake
Worth, South Palm Beach, Palm Springs, Greenacres, Wellington,
Haverhill, Palm Beach, Golden Lakes, Riviera Beach, Glen Ridge, West
Palm Beach, Lake Park, Royal Palm Beach, Jupiter, Coral Springs, Fort
Lauderdale, Parkland, Coconut Creek, Margate, North Lauderdale,
Lighthouse Point, Hillsboro Beach, Deerfield Beach, The Hamptons,
Highland Beach, Weston, Plantation, Playland Isles, Melrose Park,
Lauderhill, Sunrise, Tamarac, Wilton Manors, Oakland Park, Lauderdale
Lakes, Sea Ranch Lakes, Villages of Oriole, Pompano Beach,
Lauderdale-by-the-Sea, Boca West, Boca Pointe, Juno Beach, North
Palm Beach, Loxahatchee, Belle Glade, Palm Beach Shores, South
Miami, Cutler Ridge, Princeton, Perrine, Naranja, Homestead, Florida
City, Leisure City, Richmond Heights, Pinecrest, Howard, Coral Way
Village, Westchester, Westwood Lakes, Brownsville, Sweetwater, Key
Biscayne, North Bay Village, Miami Beach, Miami Springs, Virginia
Gardens, Hialeah, El Portal, Miami Shores, Medley, Indian Creek,
Surfside, Bal Harbour, North Miami, Biscayne Park, Pinewood Park, Opa
Locka, Bunche Park, Hialeah Gardens, Palm Springs North, Carol City,
Norland, Ojus, Miami Lakes, Biscayne Gardens, Hallandale, Sunny Isles
Beach, Golden Beach, Aventura, Uleta, Miramar, Pembroke Pines, North
Miami Beach, Hallandale Beach, Ives Estates, Pembroke Park, Coral
Gables, Kendall, Dania Beach, Cooper City, Davie, West Miami,
Hollywood, Broward County, Martin County, Miami-Dade County, and
Palm Beach County, FL. We can also offer Florida affordable family
health insurance policy quotes throughout the Sunshine state, including
in Winter Haven, Lakeland, Miami, Orlando, Tampa, St. Petersburg,
Tallahassee, and Jacksonville, FL.

Applicant Information:
Your Florida Health
Insurance Quote Source
Optimal Insurance Group
4800 North Federal Hwy
Suite D-100
Boca Raton, Florida 33431
Palm Beach County FL
(561) 342-1695
Fax: 866-314-4026
SSL Secure
Request Florida Health Insurance Quote
Proudly Serving South
Florida Since 2002!
Florida Health Insurance Quote
Optimal Insurance
Copyright 2009-2018 Optimal Insurance Group, Inc. - All rights reserved
Website Builder - InsuranceWebsiteServices.com
Florida Personal
Insurance Quotes
Health Insurance