Get a Health Insurance Quote

The Perimeter Group provides multiple ways to get an insurance quote. You can get an instant quote on-line to compare multiple carrier rates. Or, you can fill out our on-line quote form and submit it to us to have our staff look at an even greater number of carriers to get you the best rate available among our carrier roster. Finally, you can contact us via e-mail, phone or fax to start the quoting process.

In order to get the most accurate quote for insurance it is important to provide all of the information requested as accurately as possible. A good information resource is your current carrier insurance declaration pages that detail your coverage levels and other key information about your vehicles and properties.

Individual Health Quote

For the fastest and most accurate health insurance quote, please provide as much information as possible in the form below. This information will be kept confidential and will be used for quote purposes only.
Select from the following options:
Coverage For:
Please give any additional comments about the coverage you desire:

General Information

Name:*
Address:
E-mail:
Phone:
-
Best Time to Call

Current Insurance Company (not agency)

Company Name:
Policy Ex. Date:
Monthly Premium:

About Yourself

Date Of Birth:
Sex:
Marital Status
Occupation:
Height (feet & inches)
Weight (pounds):
Do You Smoke?
Have you had any of the following health conditions?
Are you currently on any prescription medications for ongoing health conditions?
If yes, please list:
Please disclose any and all health conditions you have (or had in the past):

About Your Spouse (Only if he / she is to be covered)

Spouse Date Of Birth:
Spouse Sex:
Spouse Marital Status
Spouse Occupation:
Spouse Height (feet & inches)
Spouse Weight:
Do They Smoke?
Have they had any of the following health conditions?
Are they currently on any prescription medications for ongoing health condtions?
If yes, please list
Please disclose any and all health conditions they have (or had in the past):

Children

Child #1

Child #1 Date Of Birth:
Child #1 Sex:
Child #1 Marital Status
Child #1 Occupation:
Child #1 Height (feet & inches)
Child #1 Weight:
Does Child #1 Smoke?
Has Child #1 had any of the following health conditions?
Is Child #1 currently on any prescription medications for ongoing health condtions?
If yes, please list(1)
Please disclose any and all health conditions Child #1 has (or had in the past):
Child #2
Child #2 Date Of Birth:
Child #2 Sex:
Child #2 Marital Status
Child #2 Occupation:
Child #2 Height (feet & inches)
Child #2 Weight:
Does Child #2 Smoke?
Has Child #2 had any of the following health conditions?
Is Child #2 currently on any prescription medications for ongoing health condtions?
If yes, please list(2)
Please disclose any and all health conditions Child #2 has (or had in the past):
Child #3
Child #3 Date Of Birth:
Child #3 Sex:
Child #3 Marital Status
Child #3 Occupation:
Child #3 Height (feet & inches)
Child #3 Weight:
Does Child #3 Smoke?
Has Child #3 had any of the following health conditions?
Is Child #3 currently on any prescription medications for ongoing health condtions?
If yes, please list(3)
Please disclose any and all health conditions Child #3 has (or had in the past):
Child #4

Please select the following health coverage options that interest you:

Child #4 Date Of Birth:
Child #4 Sex:
Child #4 Marital Status
Child #4 Occupation:
Child #4 Height (feet & inches)
Child #4 Weight:
Does Child #4 Smoke?
Has Child #4 had any of the following health conditions?
Is Child #4 currently on any prescription medications for ongoing health condtions?
If yes, please list(4)
Please disclose any and all health conditions Child #4 has (or had in the past):
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to provide you with a quote, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.*