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Health Insurance Questionnaire

Send your answers to Hailey to discuss your insurance needs. This is not an insurance application or a guarantee of coverage. Do not include Social Security numbers, payment details, account passwords or documents.

Required questions are marked *

Email *

Whats your name? *

Are you looking for a plan for yourself, family, or small business? * Just me My family My small business

Whats your zip code? *

Whats the best way to contact you? * Phone Email Text

List the best phone number:

Please list everyones ages and gender that you want a quote for: *

List any medications or major surgeries in the past 10 years: *

Do you smoke tobacco products? Yes No

Do you want dental and vision? Yes No Maybe

I consent to sending all answers I provide, including health information, by email to Hailey Khashan at haileykhashan@gmail.com so she can review my insurance needs, discuss available options and contact me. I understand that email may be stored, forwarded or accessed by others with mailbox access; this checkbox does not guarantee confidentiality. I may contact Hailey to discuss another way to share information instead. I am providing my own information, or I have permission and legal authority to provide the information of every other person included, including appropriate authority for any minor. I will not include employee or other adult information without their permission.

Consent is for this insurance inquiry, not marketing. Privacy information.

Talk with Hailey (678) 451-5546