Request Information and a Quote from Assurant Health Today

Fill out the form to receive a quote from Assurant Health. Compare your options to find the best policy for you!

Coverage Information
Gender Date of Birth Height Weight Smoker?
Applicant / /
Add Spouse Add Child
Health Information
When would you like coverage to start? / /
Are you currently insured? yes no
If yes, who is your current insurance company?
Do you currently take any medications? yes no
Please specify:
Do any of the people applying for insurance have any pre-existing health conditions? yes no
Please check all pre-existing health conditions that apply:
 
Contact Information
First Name Last Name
Address City
State Help Zip
Primary Phone - - Alternate Phone
(optional)		 - -

  I have read and agreed to all Privacy Policies and authorizations.

Authorization

By selecting "Request a Quote," I have read and agreed to all Privacy Policies, and and I hereby authorize Assurant Health to share the information that I have provided in this website, including my name, contact, coverage and minimal health information to Assurant Health or other insurance agents who may contact me in regard to my request for a health insurance quote and additional health insurance coverage information.

The information shared with the Assurant Health or other agents will be used in the scope of offering insurance quotes and products to me. I understand that Assurant Health may receive remuneration from the agents in exchange for sharing my information.

I have been informed via this authorization that the information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by the federal privacy law.

I understand that I may revoke this authorization at any time by notifying Time Insurance Company in writing of my desire to revoke. Such revocation must be sent by certified mail to the following address: LEGS, Time Insurance Company, P.O. Box 3050, 501 West Michigan, Milwaukee WI 53201-3050. Such revocation will not be valid if Time Insurance Company has taken action in reliance on the authorization.

This authorization expires 60 days following the date of the electronic signature of this authorization. A copy of this authorization will be valid as the original. Please print a copy for your records.   I understand that I may refuse to sign this authorization; however if I do not sign Assurant Health will not be able to share my information with an agent to provide me with a quote for insurance. We want you to feel comfortable using our site and requesting a quote or further information, and we urge you to familiarize yourself with the Assurant Health Legal Notice and Privacy Policy.

Product options depend upon the plan selected. Not all plans available in all states. Preferred rates subject to underwriting approval. Members must qualify for particular discounts.
Top