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Primary Applicants Name

Street Address

City

County

State

Zip Code

Home Phone

Cell Phone Number

Email Address

If your woking with an existing People First Advisor please indicate look for your advisor here Melody Blaise Jason Lybrek Sharlene Hill Marcus Franquez Charles Davis Rita Gomez Linda Stone Vinson Davis David Riddle Leroy Hibberd Lashonda Taylor Kris Carranza Lydia Leonard Marcia Chance Sylvia Cherry Jeff Richardson Roberta Santiago Tony Antin David Oliver William Avery Rodney Ferguson Javier Del Pino

What type of insurance do you need ? Individual Major Medical Group Medical Plans Medicare Advantage Plans Medicare Supplements Low Cost Discount Health Plans Life Insurance Dental Insurance

Are you curently Insured ?

When do you need your covergae to start

Best time to contact you. Hours 01 02 03 04 05 06 07 08 09 10 11 12    :  Minutes 00 15 30 45   AM PM

Who needs coverage ? 1 Adult 1 Adult + Spouse 1 Adult + Spouse and 1 Dependent 1 Adult + Spouse and 2 Dependents 1 Adult + Spouse and 3 Dependents 1 Adult + Spouse and 4 Dependents 1 Adult + Spouse and 5 Dependents 1 Adult + 1 Dependant 1 Adult + 2 Dependants 1 Adult + 3 Dependants 1 Adult + 4 Dependants 1 Adult + 5 Dependants One Dependant Only Two Dependants Only Three Dependants Only Four Dependants Only Five Dependants Only

Applicants information Male non Smoker Female non Smoker Male Smoker Female Smoker

Date of birth

Pre-existing medical conditions ?

Spouse Information Female Non Smoker Male Non Smoker Female Smoker Male Smoker

Date of Birth

Pre-existing medcal conditions ?

Child 1# information Female Non Smoker Male Non Smoker Female Smoker Male Smoker

Date of Birth

Pre existing medical conditions ?

Child 2# Information Female Non Smoker Male Non Smoker Female Smoker Male Smoker

Date of Birth

Pre-existing medical condition ?

Child #3 Information Female Non Smoker Male Non Smoker Female Smoker Male Smoker

Date of Birth

Pre-existing medical conditions ?

Child #4 Information Female Non Smoker Male Non Smoker Female Smoker Male Smoker

Date of Birth

Pre-existing medical conditions ?

Child # 5 Information Female Non Smoker Male Non Smoker Male Smoker Female Smoker

Date of Birth

Pre-existing medial conditions ?

Comments

Welcome!

• What about our name? People First, Insurance Outreach Agency:
• We are an outreach minded organization.
• Because we don’t represent one company, we are able to look at the options that are best for you, not the insurance company.
• We enjoying finding creative and innovative ways to get you the maximum amount of insurance coverage with the least amount of cost.

securing your Future:Health Insurance is a very important part of being financial secure. Unfortunately, thousands of Americans have major financial burdens because of the lack of insurance.You need the peace of mind of knowing that when sickness occurs in your family, you have provided the ability to get the health   care service your family needs.

 

We specialize in the following areas: