GT INSURANCE AGENCY INC
                                 14221 Euclid Street Unit J, Garden Grove, CA 92843
                                           Bus: 714-539-8484 Fax: 714-539-5484
                                                 Email: nic@gtinsurance.net
                                                          License # 0H65115
                                                   

                                          Health Quote Sheet


Client Information:                                                     

1.        Effective Date_________________________________
2.        Subscriber’s Name ______________________Age_______DOB_________
3.        Spouse’s Name _________________________Age_______DOB_________
4.        Zip Code_____________ Number of Children under 1 yrs. ________
5.        Number of Children Between 1-18 yrs_____________
6.        Home Phone ______________Work Phone _____________Cell___________

Coverage Requested:

  • Traditional Health PPO or HMO (Circle one)         
  • Dental PPO or HMO (Circle one)
  • Vision
  • HSA
  • Emergency & Hospital Only
  • Other

Reason for coverage    _____________________________________________________________

  • I would prefer a plan with a higher annual deductible or office visit co-pay and a lower monthly rate.

  • I would prefer a plan with a lower annual deductible or office visit co-pay and a higher monthly rate.


Co-pay (Select one)          $30                  $40                   $50

Remarks/Notes