Affiliated Insurance

2500 Apalachee Pkwy
Tallahassee FL 32301
Across from Pep Boys

(850) 877-6660
(800) 877-6180
Contact Us

Hours of Operation:
Monday - Friday
8:30am - 5:30pm
Saturday
10am - 2pm
Closed Sunday

Request for Health Insurance Quote

Life Insurance Information

Type

Amount of Death Benefit

Insured Information

First Name:

Last Name:

You must provide your last name.

Telephone Number:

You must provide your telephone number.

Email Address:

Address:

City:

State:

Postal Code:

Date of Birth

Use Tobacco

Gender

Height

Weight

Insured Medical Information

Describe any pre-existing Health conditions

List below any medication, including dosage and frequency

Note any other pertinent information or requests for coverage

Spouse Insurance Information

Spouse to be Insured?

Spouse Date of Birth

Spouse Use Tobacco?

Gender

Height

Weight

Children

Spouse Medical Information

Describe any pre-existing Health conditions

List below any medication, including dosage and frequency

Note any other pertinent information or requests for coverage

Children Information

	Date of Birth	Gender
Child 1
Child 2
Child 3

Children Medical Information

Describe any pre-existing Health conditions

List below any medication, including dosage and frequency

Note any other pertinent information or requests for coverage

Disability Insurance Information

Occupation

Duties

Earnings

Earnings Frequency

Other Disability Coverage?

Other Disability Coverage Type

Disability Benefits to be Quoted

Elimination Period STD

Percentage Payable STD

Maximum Monthly Benefit STD

Duration of Benefits STD

Elimination Period LTD

Percentage Payable LTD

Maximum Monthly Benefit LTD

Duration of Benefits LTD

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.