California Health Insurance Quote from Adams Avenue Insurance Agency

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10 Reasons Why You Should Use Adams Avenue Insurance Agency:

1. The best coverage at the lowest price.

2. Instant phone quotes for most products.

3. Low down payments.

4. Easy monthly installments.

5. Internet quotes returned within 24 business hours.

6. We have carriers that will insure houses with prior claims and that are in brush areas.

7. Rates are shopped exclusively for you with 25+ auto and home insurance companies.

8. Huge discounts on ALL insurance products!

9. Our experience allows us to match you with the carrier that best meets your needs.

10. We have been saving our customers money on insurance since 1988.

On-Line Health Insurance Quotation Form One Simple Form - takes only 2-3 Minutes! *Your Personal Data*
Your Name:
Street Address:
City:
State: (Must be California)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):

Marital Status: Single Married	Do You Own Your Own Business? Yes No

Health Ins. Currently? (If yes, list carrier, and # of years continuous. If none, type N/C)

UNDERWRITING INFORMATION

Insured Name: Birthdate:

Insured Height: Insured Weight:

Insured Occupation: Hazardous Activities? (if yes, describe):

Sex (M/F): List children's
ages to be covered

Be as specific as you can on the underwriting questions below so we may find the most competitive product for you!

Do You use tobacco? Yes No Describe usage (cigar, cigarettes, etc.)

Any Pre-existing Health Conditions?
(If yes, descibe in detail, and to which of the insured persons they apply.)

Any Covered Persons Currently Taking Medication of Any Kind?
(If yes, descibe in detail, and to which of the insured persons they apply.)

COVERAGE INFORMATION

How Long Do You Need Coverage For?
(if short term, etc.)

What Deductible Do You Want?
($250, $500, $1000, etc.):

Any special coverages needed?
(Maternity, H.M.O., P.P.O., etc.)

Tell Us What You Want MOST in your Health Plan, or list any other Remarks here:

Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone!

Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me My
Health Insurance Quote NOW!

Click Button Below When Done

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Adams Avenue Insurance
9114 Adams Ave., Suite 144
Huntington Beach, CA 92646
Phone: 1-714-593-1914 / Fax: 1-866-832-4186
E-Mail us at: dave@adamsaveins.com