Insurance Home Quote - Excel - Excel

							Flippo Insurance                                                                                bcf5fe60-de87-48c0-af58-cb782a3281c5.xls
                                                                                                                 Census
Quoting Agent: Roger Flippo
                                                                                                                2/22/2011




                      Applicant Name                                                                                      Agency           Flippo Insurance         Agent Name                        Roger Flippo

          Applicant Residence Address                              City/State                                     Agency Address       751 W New Orleans St         Agent's Phone Number              918-455-0554

                         Home Phone                                       Zip                                                  City         Broken Arrow            Agent's Fax Number                918-455-0592

                      Business Phone                            Business Fax                                                  State              OK                 Agent's e-mail                 rflippo@flippoinsurance.com

                           Cell Phone                                 e-mail                                                    Zip             74011               Proposed Effective Date


                                                                                Smoker/ Non
               Name                      DOB          Age        Gender           Smoker         Height              Weight           Pre-existing Conditions                 Medications Taking    Primary Physician   Current Carrier

Applicant

Spouse

Dependents:

                           Child #1

                           Child #2

                           Child #3



Indicate below with a √ next to the benefit options you would like included in your health insurance quote

Office Visit Copay                             $15                        $20                             $30                                                 $40
Deductible                                  $500                    $1,000                            $1,500                                             $2,500                                               $5,000
Coinsurance                             70%/30%                   80%/20%                          90%/10%                                              100%/0%
Prescription                              Copay                   Discount
Maternity                                      Yes                        No
Hospital of Choice                      St John's             Saint Francis                         Hillcrest                                      SouthCrest                                       Tulsa Regional
Provider Network                                Preferred Community Choice                    PPO Oklahoma                                                 PHCS                                         First Health


Optional Coverages                        Dental                    Vision                                Life                                           Cancer                                            Accident
Notes




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