Low Cost California Short Term Medical and Health Insurance Quote from CA Health Insure.com

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On-Line Short Term Medical Insurance Quotation Form One Simple Form - takes only 2-3 Minutes! *Your Personal Data*
Your Name:
Street Address:
City:
State (Must be California):
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone (in case we need more info.):
Fax (optional):

If you Currently have Health Insurance or COBRA in force, when will it end?

UNDERWRITING INFORMATION

Insured Name: Sex (M/F): Birthdate:
Spouse Name: Sex (M/F): Birthdate:
Include Spouse?:	Yes No	Include Children?:	Yes No
List children's names & birthdates to be covered: (up to 6 children)	Name:B-Date:Sex: Name:B-Date: Sex: Name:B-Date: Sex: Name:B-Date: Sex: Name:B-Date: Sex: Name:B-Date: Sex:
Be as specific as you can on the underwriting questions below so we may find the most competitive product for you!
Do You use tobacco?	Yes No	Describe usage (cigar, cigarettes, etc.)

Any Pre-existing Health Conditions?		(If yes, descibe in detail, and to which of the insured persons they apply.)

Any Covered Persons Currently Taking Medication of Any Kind?		(If yes, descibe in detail, and to which of the insured persons they apply.)

*COVERAGE INFORMATION*

How Long Do You Need Coverage For? (if short term, etc.)

What deductible are you interested in (if none selected all will be quoted) ($250, $500, $1000, $2500, etc.):

Please give any additional Comments, Questions or Remarks here:

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Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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