Health Savings Account Proposal Request

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G. A. MacDonald Associates, Inc.

Financial Management & Insurance Services
2200 Lake Avenue, Suite 120, Fort Wayne, Indiana 46805
Phone: (260) 422-5377 Fax: (260) 423-6780

Health Savings Account
Proposal Request
(Indiana Residents Only)

Please complete the following form and click the "Submit for Quote" button to request a FREE Health Insurance Proposal. Final premium is subject to verification of information and underwriting approval.

General Information

Name:

Street Address:

City: State: Zip Code:

Email Address: Phone Number:

Marital Status:

Self-Employed?: Occupation?:

Coverage Information

In the past five years, has any person to be quoted been treated for or diagnosed with (please explain any "Yes" responses below)...

Diabetes?		ADD or ADHD?
Heart Attack or Stroke?		Cancer?
Depression?		AIDS?
Any other unlisted major health conditions?
In the past 5 years has any person to be quoted taken part in flying as a pilot, parachuting, hang gliding, underwater diving, auto racing, or driving or riding as a passenger on any type of motorcycle; or does any person expect to take part in any of these activities in the next 2 years?
Is any person to be quoted currently pregnant?
Has surgery, testing, or treatment been recommended which has not been completed for any person to be quoted?
Is any person to be quoted currently taking prescriptions for any condition?
Please explain any "Yes" responses here:

Are you currently insured?
If "Yes," which company?
If "Yes," tell us a little about your current plan (e.g., what is your deductible, any copays for office visits/prescriptions?, etc.)
If "Yes," how much do you pay per month?	$ per month
How much would you like to pay per month?	$ per month

Family Information

	Gender	Age	Height	Weight	Tobacco User?
Applicant
Spouse
Child
Child
Child
Child
Child

Other Information

Is there anything else you would like us to know? Do you have any questions or comments?

Thank you for your submission. Someone from our office will contact you no later than the next business day. If you have any immediate questions, please contact Dave MacDonald at (260) 422-5377.

Check out our GREAT RATES for CONTRACTORS Liability, Vehicle, and Workers Compensation Insurance!

Health Savings Account Proposal Request (Indiana Residents Only)

For general information e-mail: Dave MacDonald G. A. MacDonald Associates, Inc. Fort Wayne, Indiana

Health Savings Account
Proposal Request
(Indiana Residents Only)

For general information e-mail: Dave MacDonald
G. A. MacDonald Associates, Inc.
Fort Wayne, Indiana