Health Insurance Quote Request

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote.

PRIVACY PRE-NOTIFICATION: The Howard French Insurance Agency has a privacy policy to protect and keep this information confidential and will be used for quote purposes only.

* Required fields.

General Information
*Name:
*Address:
*City:
*State:	Zip:
*Phone:
Best Time To Call:	AM PM
*E-mail Address:

Current Individual Health Insurance Information
Carrier (Company) Name (not agency):
Policy Expiration Date:	Premium Amount: $
Years Insured:
Please give a brief description of your current health plan, if applicable:

*Benefits Desired
Major Medical Deductible:		Optional Pregnancy Coverage:	Yes No
Dental Coverage:	Yes No	Supplemental Accident Coverage:	Yes No
Disability Insurance:	Yes No	PCS Card: (Prescription Disc Option)	Yes No
Life Insurance:	Yes No	PPO Option:	Yes No
Amount:	$	HMO Option:	Yes No

*Existing Health Problems

Any health problems that could affect premium? Please explain.

Additional Comments or Questions

Please click the "Submit Quote" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.

**Privacy Policy Notification**

In order to determine your eligibility, we are required to verify your loss history and credit history using consumer reports. You understand and agree that any personal information about you that you provide or that we obtain from any consumer report may be used by any company within the Nationwide Insurance group of insurance companies to issue, review and renew the insurance for which you are applying. You have the right to access and correct all personal information collected.

If you do not want us to order a credit and claims report, we can still provide you with a conditional quote; however without these reports, the quote may be rather inaccurate and cannot be used as final rates for your mortgage company or budgetary purposes.

The Howard French Insurance Agency

5541 Cabat Lake Court
Fairfax, Virginia 22032
703-738-4800 office | 703-738-4488 fax

8220 Jones Road, Suite 100
Houston, Texas 77065
281-677-9491 office | 281-677-9492 fax

"The greatest compliment we can receive is your referral."
Proud Member of the Barhorst Insurance Group