Welcome to
THE ABBOTT & FILLMORE AGENCY, INC.'S

MED QUOTE

at insurancearizona.net

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INSURANCE FOR ARIZONA ON THE NET!
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INDIVIDUAL MEDICAL INSURANCE QUOTE SERVICE

Note: If you own a business, we may also be able to get you group coverage under your business.  Contact us immediately at 1-800-243-6296 for more information.

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Please enter the following information

BASIC INFO:

Your Name:

Your email address:              
Your home phone number:    
Your work phone number:    
Your fax (if want quote faxed):
Your home street address:    
Your city:                             
Your State:                   
Your ZIP Code:                   

Input all people you want to cover under the medical insurance INCLUDING YOURSELF AGAIN
Name Sex (M or F)

Birthdate
Smoke?
YorN
 Ht. Wt. Relationship to you
How is everyone's health? It is important that you answer this as truthfully and completely as possible.  There is no sense in going through this only to have the company that we submit it to reject it or deny a claim in the future..
Please explain the general health of all people to be insured.  Does anyone have any issues?  Is anyone on any prescription drugs?  Please give names and details.

Do you have any medical insurance now?  If so, who is it with and why are you looking to change?

If you do have medical insurance now, what is your monthly premium?

How did you find our Web Site? 

Did you find our quote form easy to use?  Put any ideas for improvements here.  Also put any additional comments or information you may have.

Thank you for completing our online quote form. Please let us know how you would like us to send you the quote: E-Mail Fax  (Did you enter your fax # above?   Phone Call