Health Insurance Solutions, Inc. - Health Care Solutions

The Hunsicker Building
177 North Main Street
Souderton, Pa 18964

1-877-939-HISI
(215) 721-2220
hisi@gethisi.com

Price Quotes

Price Quotes for our Business and Individual Products.

QUOTE REQUEST- INDIVIDUAL / FAMILY / GROUP PLANS

FIRST NAME
LAST NAME
DATE OF BIRTH
TITLE / DEPARTMENT
BUSINESS NAME
STREET ADDRESS / P.O. BOX
CITY
STATE
ZIP CODE
PHONE
FAX
E-MAIL ADDRESS
SUBSCRIBE TO OUR MAILING LIST We will periodically send updates and information about our products and services.	YES NO
CURRENT CARRIER
MONTHLY PREMIUM
QUOTE STATUS Check one	INDIVIDUAL / FAMILY GROUP / CORPORATION
CURRENTLY CONSULTING WITH A BROKER Check one	NO YES
Are you agreeable to issue "Broker of Record" to HISI ? Check one	NO YES
PRODUCTS & SERVICES OF INTEREST Check item or items where we may spread sheet cost-saving options	SELF-FUNDED FULLY-FUNDED MEDICAL RX DENTAL VISION AD&D STD LTD SUPPLEMENTAL
COMMENTS Please add any additional comments or important notes here
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