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GIG Insurance Quote Request Form

Comparison quotes will be generated from our top-rated insurance carriers, at the most affordable rates and within 48 hours of submission. Please complete all applicable fields below to receive an accurate estimated quote.

         Once a quote is provided to you, please contact a Global Insurance Broker for further details.

 Select the appropriate insurance type for this quote   

Section 1: Contact Information                                                                                                                       

Full Name *  
Email address*  
Fax Number  
Telephone No.*  
How would you like to receive the quote?  

            Please answer all relevant medical questions as they apply to you and your dependents.

Section 2: Personal Information
 
Date of Birth (mm/dd/yyyy) *
Zip Code *
State / County *
Gender * Female Male
Height *     Feet Inches
Weight *  
Have you used Tobacco within last 12 months? *  Yes    No
During the last 2 years how long have you lived in the US?  Years  Months
Are you a US citizen? Yes    No
Immigration Status  
   
Section 3: Spouse Information
 
Are you requesting child or spousal coverage? *  Yes    No

 If Yes, input information about Spouse and Children below. If No, skip to next section.

Spouse Gender  Female Male
Spouse Date of Birth
(mm/dd/yyyy)		  
Spouse Height  Feet Inches
Spouse Weight:  
Has your spouse used Tobacco within last 12 months?  Yes    No
How long has your spouse been in the US?*  Years  Months
Is your spouse a US citizen?  Yes    No
Spouse Immigration Status  
Section 4: Children Information
Do you have any children to be covered?  Yes   No
Number of children to be covered:
Ages 
Gender (M or F)
Section 5: Current Insurance
Are you currently insured? *                                  (if yes, please answer questions below) Yes   No
If so, with what company?    
Currently Monthly Premium  $
Current In-Network Deductible  $
Current In-Network Co-Insurance 50/50   70/30  80/20
Current In-Network Out of Pocket Limit  $
Section 6: Other questions
Some medical conditions result in rate increases or exclusions.  Please list any and all medical conditions for each applicable family member along with dates of treatment.
 
Check if you or anyone requesting coverage have been diagnosed in past 10 years: AIDS/HIV   Heart Disease  Mental Illness  Alzheimer’s Disease Kidney Disease   Cancer COPD   Liver Disease   Stroke
Do you need maternity coverage:  
Are you interested in a Health Savings Account?                     Yes  No                                                       
Preferred Monthly Premium Range  $
Preferred Annual Deductible Range $
Preferred In-Network Co-insurance   
Preferred In-Network Out of Pocket Limit $
Life Insurance Coverage Type:    
Life Insurance Coverage Amt:   
Is there anything else you want to tell us?
                                   

     

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