LSS Insurance
Please fill in the information below so we can provide you with a quote on your health Insurance. Or give us a call with the information. (435) 752-9493
Individual and Family Quote Sheet
Your name:
Mailing address:
City:
State:
ZIP:
Country:
Telephone:
Fax:
E-mail:
Contact preference?:
Telephone:
Fax:
E-mail:
Your date of birth:
Smoker?
Yes
No
Spouse date of birth:
Smoker?
Yes
No
Children ages and sex:
Is any member of the family taking prescription medications or being treated for any medical condition? Any hospital stays over the past 10 years ? Please provide as much information as possible:
Comments:
If you have current insurance, it would be helpful to
know why you are considering a change:
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