Pallay Insurance Agency
   P.O. Box 727
   Mokena, IL 60448
   Phone: 888.549.8533
   Fax: 800.428.9163



Pallay Insurance Inc. Home

 PLEASE INDICATE WHICH PLAN(S) YOU WOULD LIKE QUOTES FOR
 
Medical          Short Term Medical           Limited Benefit Fixed Indemnity
 
Medicare Supplement           Prescription Drug Only        Dental
 Plans may not be available in all counties

First Name:
_____________________

PPA Member Name:
(if different than above)

 

Last Name:
______________________

PPA Member Last Name:
(if different than above)



 

Phone:

 

Fax:

 

Email:

 

   


Be assured that all information you provide here is secure. Please reference our
Privacy Policy for more information on our commitment to using information provided here strictly in conjunction with obtaining health insurance.

Quote Request Form (v2.5)

Street Address:

 

City:

 

State:

           Zip:

County: (please do NOT give us Country like USA for example)

Date of Birth:

 

Sex:

 'M' or 'F'

Height:

 feet inches

Weight:

 Numbers Only

Tobacco User:

 'Y' or 'N'

   

Annual Household Income:

Include income from all members in the household, even if all not requesting quotes

(determines insurance premium subsidy eligibility)

Are you, or spouse if married, eligible for health insurance from an employer:

 'Y' or 'N'

   


Spouse Information
(complete only if spouse is to be included in quote)

Date of Birth:

 

Sex:

 'M' or 'F'

Height:

 feet inches

Weight:

 Numbers Only

Tobacco User:

 'Y' or 'N'

   

Children's Information
(complete only if children are to be included in quote)  

Child #

Sex

Date of Birth

Height

Weight

1

 'M' or 'F'

 

 ft. in.

 

2

 'M' or 'F'

 

 ft. in.

 

3

 'M' or 'F'

 

 ft. in.

 

4

 'M' or 'F'

 

 ft. in.

 

5

 'M' or 'F'

 

 ft. in.

 

6

 'M' or 'F'

 

 ft. in.

 

Coverage Information

Number of persons in family to be insured:

Do you have insurance now?

 'Y' or 'N'

Name of Current Insurance Company:
Current Monthly Premium:

Answer the following questions ONLY if you are requesting quotes for a Limited Medical Insurance or Short Term Medical Insurance

Are you, your spouse, or any person to be insured now pregnant, an expectant
parent, in the process of adopting a child or undergoing infertility
treatment?

 'Y' or 'N'

Are you, your spouse, or any person to be insured totally and permanently
disabled and/or receiving long-term disability benefits?

 'Y' or 'N'

For any of the following conditions within the last 5 years, have you or any
person to be insured received any abnormal test results or medical or
surgical treatment, or consulted a health care professional, or taken
medication for:

* Heart disorder, excluding Mitral Valve Prolapse (MVP) or surgically corrected or closed Atrial Septal Defect (ASD)/Ventricular Septal Defect (VSD)
* Stroke or Brain Aneurysm
* Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
* Crohn's Disease or Ulcerative Colitis
* Liver disorders, excluding fully recovered Hepatitis A
* Kidney Disorders, excluding kidney stones
* Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Fibrotic Lung Disease or Primary Pulmonary Hypertension
* Diabetes, excluding Gestational Diabetes
* Basal Cell Carcinoma with recommended surgery that has not been completed
* Cancer or Tumor
* Alcoholism, Alcohol or Chemical Dependency, or Drug or Alcohol Abuse
* Multiple Sclerosis (MS)
* Tuberculosis (TB)
* Any condition that resulted in a surgery or procedure whose purpose is to promote weight-loss
* Autism Spectrum Disorders, Autism, Asperger's Disorder, Rett's Syndrome, Pervasive Developmental Disorders or Pervasive Developmental Delay

 'Y' or 'N'

Within the last 5 years have you or any person to be insured tested positive
for or received any diagnosis, medical or surgical treatment by a medical
professional or taken medication for Acquired Immune Deficiency Syndrome
(AIDS) or Human Immunodeficiency Virus (HIV)?

 'Y' or 'N'

Applicant's Questions or Comments

 

Upon submitting your Quote Request, an email will be sent to Pallay Insurance Agency. You will be taken to a "Success" page after completing transmission.

Thank you for your request!
 

Note: This information will not be used for any other purpose except to generate a quotation for insurance. Any quotations generated are for your information only and are intended to be rough estimates. Actual quotations will only be issued after more complete information has been gathered, which will be made easier by completing this form. For any questions, do not hesitate to call us toll free at 1.888.549.8533.

 

 


 
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