Our Health Insurance Carriers

• Aetna
• Assurant
• Blue Cross/Blue Shield of AZ
• Cigna
• CSA (Dental)
• Delta Dental
• EDS (Dental)
• Healthnet
• Humana
• Metlife
• Securecare Dental
• United Healthcare
• VSP (Vision)

Individual Health Insurance Application

Pritchard Group Insurance simplifies shopping for individual health insurance. Fill out our short, easy form and we'll shop for companies who will compete for your business and find you the best value. Get started now.

Primary Insured's Name:	*
Street Address:	*
City / State / ZIP:	*
Home Phone (please include area code):	*
Cell Phone:	*
Business Phone:	*
Email:	*

Number of Dependents to be Insured:
Maternity Coverage Required?
Smoker?	Yes No
Current Insurance Carrier:
Type of Plan (HMO, PPO, etc):
Premium $:
Requesting Dental Coverage?

Primary Insured's Date of Birth:
Sex:
Height:
Weight:
Known Medical Conditions:
Medications:

Spouse Date of Birth:
Sex:
Height:
Weight:
Smoker?	Yes No
Known Medical Conditions:
Medications:

Child #1 Date of Birth:
Sex:
Height:
Weight:
Smoker?	Yes No
Known Medical Conditions:
Medications:

Child #2 Date of Birth:
Sex:
Height:
Weight:
Smoker?	Yes No
Known Medical Conditions:
Medications:

Child #3 Date of Birth:
Sex:
Height:
Weight:
Smoker?	Yes No
Known Medical Conditions:
Medications:

Please send me a quote based on the information
I have provided in this on-line application form.