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Get A Quote
To obtain a quote, just provide the information requested below and you will receive the rates for the plan of your choice, along with a comparison of rates for our other plan options.
* Indicates required fields
First Name:
Last Name:
Address:
City:
* Florida County :
Broward
Dade
Hillsborough
Lake
Orange
Osceola
Pasco
Pinellas
Polk
Seminole
*Zip Code:
*Email Address:
Daytime Phone:
-
* Effective Date:
9/1/2010
10/1/2010
11/1/2010
12/1/2010
You may request a quote for a future effective date, but please note that all Enrollment Applications are only valid for a period of 60 days beyond the signature date.
* Benefit Plan:
To view a summary of benefits,
click here.
* Prescription Drug Benefit Plan
NO RX
RX1
RX1-($0 deduct)
RX2
RX2-($250 deduct)
RX3
To view a summary of benefits,
click here.
Age
Gender
Tobacco
Usage
* Primary Applicant
Male
Female
Select
Yes
No
Spouse
Male
Female
Select
Yes
No
*
Maternity Rider:
*Required field for female applicants, age 18 to 51, not available for dependent children
Yes
No
Dependents
Full-time
Post-secondary
Student?
Age
Gender
Child 1
Yes
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
?
Male
Female
Select
Child 2
Yes
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
?
Male
Female
Select
Child 3
Yes
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
?
Male
Female
Select
Child 4
Yes
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
?
Male
Female
Select
(For children under 1 year of age, enter the age of 0)
(For child only quotes, please input the youngest child as the primary applicant. All other children should be listed in the child section.)
(Full-time, post-secondary students may be covered as dependent children until their 23rd birthday.)
Should you have any questions, need assistance, or would prefer to consult a Sales Professional, please contact your agent, or our Sales Team toll free at 1-866-769-1157 Monday through Friday, 8:30 am to 5:00 pm, EST.
The rates that are quoted here are NOT guaranteed. All final rates will be determined upon completion of the underwriting process and approval of the Application for Enrollment.
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H5407CHC0298IT01E (Pending CMS Approval)
S8465CHC0299IT01E (Pending CMS Approval)
3/17/2010