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Name
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First
Last
Contact Information
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Contact Number
Email Address
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Currently on a Health Plan?
*
No
Yes
Current Company & Plan
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ALL People to be Covered
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Full Name
ID Number
Including Main Member
Medical Aid or Hospital Plan?
*
Medical Aid - I need savings
Hospital Plan - I don't need savings
Unsure - Quote Both around Budget
Approx. Budget I want to pay
*
Companies to Quote
*
Discovery Health
Fedhealth
Medihelp
Momentum Health
Bonitas
Other
We can quote 4 companies at a time side by side for comparisons.
Other Company
Any Pre-Existing Conditions, Chronic or Illnesses to Note?
*
Consent
*
I confirm that the above information is true and correct
This completed questionaire is used for quotation purposes only and a guideline based on this information.
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