Thursday, March 11, 2010
Illinois Health Insurance Basics
Products & Solutions
Illinois Health Insurance Carriers
Healthcare in Illinois’s Cities
Illinois Health Plans works with insurance agents and carriers across the country that will use the information you provide below to give you accurate insurance quotes. You may be contacted by phone by up to four agents who will help you compare plans and select the policy that is right for your needs.
Step 1 of 2: Medical Profile
Gender
Date of Birth
Height
Weight
Smoker?
Full-time College Student?
Applicant
*
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M
F
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Spouse
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Children
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What is this?
Child 1
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M
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Please select your gender.
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Child 2
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M
F
Please select your gender.
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Child 3
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M
F
Please select your gender.
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Child 4
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M
F
Please select your gender.
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In
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Child 5
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M
F
Please select your gender.
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In
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Are you currently insured?
*
yes
no
If yes, who is your current insurance company?
--Select--
Aetna
Assurant Health
Blue Cross
Blue Shield
Celtic Insurance Company
CIGNA
Golden Rule Insurance
Group Health Cooperative
Group Health Incorporated (GHI)
Health Net
HealthPartners
Humana
Intermountain Health Care (IHC)
Kaiser Permanente
LifeWise Health Plan
Medica
Medical Mutual of Ohio
Midwest Security
Oxford Health Plans
PacifiCare
Tufts Health Plan
UNICARE
United HealthCare
United Wisconsin Life/AMS
Vista Health Plan
Other
When would you like coverage to begin?*
3
4
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6
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22
23
24
25
26
27
28
29
30
31
/
2010
Do you currently take any medications?
*
yes
no
Please specify:*
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
Step 2 of 2: Contact Information
First Name
*
Last Name
*
Address
*
City
*
State
*
--Select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
*
Day Phone
*
-
-
Evening Phone
*
-
-
Contact Time
*
Anytime
Morning
Afternoon
Evening
Email
*
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