Health Insurance Quote

Providing “Low Cost - Best Value" Health & Medical Insurance Quotes to the self-employed, family, individual, student, dependent only or COBRA recipient in the states of Minnesota, Texas and Wisconsin.

IMPORTANT NOTE: We cannot provide a quote unless ALL " * " fields are completed!

Name:
Address:
City/State/Zip:
Phone:	Eve: Day:
Fax:
E-mail:

Type of product
Dental	Yes No
Health	Yes No
International Travel Medical	Yes No
Life	Yes No
Short-Term Medical	Yes No
Student Select	Yes No
Vision	Yes No
Medical Savings Account	Yes No

Type of policy
Individual	Yes No
Spouse	Yes No
Children	Yes No
Sex	Individual: Spouse:
Individual D.O.B.: Spouse D.O.B.:
Tobacco Use:	Individual: Spouse:
Number of Children	Ages:

Health of America Insurance Agency
2901 S Wayzata Blvd., Minneapolis, MN 55405-2126
Phone: 612-377-3222 or Toll Free 1-800-868-2333
Fax: 612-377-3444
Business hours: M-F 8:30 am - 5:00 pm CST