Affordable Health Plans

	Gender	Date of Birth
Applicant*		/ /
Spouse	Please select your gender.	/ /
Children		What is this?
Child 1 :	Please select your gender.	/ /
Child 2 :	Please select your gender.	/ /
Child 3 :	Please select your gender.	/ /
Child 4 :	Please select your gender.	/ /
Child 5 :	Please select your gender.	/ /
Child 6 :	Please select your gender.	/ /

Are you currently insured?*

yes no

Who is your current insurance company?

When would you like coverage to begin?*

/ /

Do you currently take any medications?*

yes no

Do any of the people applying for health insurance have any pre-existing health conditions?*

yes no

Please check all pre-existing health conditions that apply to any of the people listed above:
	Aneurysm	Cancer	Clinical Depression
	Diabetes	Drug/Alcohol Abuse	Emphysema
	Heart Disease	HIV/AIDS	Hypertension
	Kidney Disease	Liver Disease	MS
	Paralysis	Stroke	Other Major Illness

First Name*		Last Name*
Address*		City*
State*		Zip*
Day Phone*	- -	Evening Phone*	- -
Contact Time*		Email*

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The information on this page will be used to provide you with accurate health insurance quotes from up to eight agents. You may be contacted by telephone regardless of whether you are on the Do Not Call Registry. You also agree that we may contact you at the above-listed phone number with a pre-recorded message to verify your interest.

Studies show that insured Americans are more likely to receive preventative healthcare, ensuring a happy and healthy future. Finding the right health insurance policy can be a challenge, however, and Affordable Health Plans is here to help. We know that high premiums can put a strain on your family's finances, and we are here to help you find the coverage you need at a price you can afford.

With our straightforward and easy process, you can get the healthcare you need.

Simply fill out our one-page form to apply.

It's that simple! Don't wait to make sure that you and your family are covered in the event of a medical emergency.