Global Insurance Group
 
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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 24 hours of submission.  Please complete all applicable fields below to receive an accurate estimated quote.  Submission of application will determine final rates.

        

 Select the appropriate Insurance Type for this quote   

Section 1: Personal Information                                                                                                                              

Full Name *
Home Street Address *
City, State, Zip, County *
D.O.B *
Gender / Height / Weight *
Tobacco Usage *
Phone (home / work / cell) *
Email Address *
How would you like to receive the quote?  

            Please answer all relevant questions as they apply to you and/or your business....

Section 2: Business Information
 
Effective Date *
Company Legal Name *
Business Street Address *
City / State / Zip *
Business Operating Status
No. Years in Business *
Brief Description of Business *
Years of Owner Experience within Industry *
No. of Employees *
Gross Annual Revenues
Gross Annual Payroll
Business Insurance Needed *
   
Section 3: Spousal Health Information (if applicable)
 
Are you requesting child or spousal health 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: Childrens Health Information (if applicable)
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 Annual Deductible  $
Section 6: Other Health Questions (if applicable)
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 medical 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 $
Life Insurance Coverage Type:    
Life Insurance Coverage Amt:   
Is there anything else you want to tell us?
                                   

     

 

  

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All rights reserved.

Commercial International Personal  Request Quote  Supplemental