AMERICAN LIFE & HEALTH GROUP, INC.     
 

For A Free No Obligation Quote, Designed Just For Your Individual Requirements, Complete The Information Form Below. Thank You, We Will Have A Two Or More Option Quote To You Within 24 Hours.

 

[FrontPage Save Results Component] First, tell us what type of insurance are you inquiring about:

All   Health Insurance  Life Insurance    Medicare Supplements  Annuities   Other

Insurance for Self Only  Self & Spouse  Self &  Child Self, Spouse & Children

First Name:       Last Name: 

Address:         Apt. # or Suite #

City:                 State     Zip:  

Phone Number:    Phone Number 2:

Email Address:    Preferred to be contacted by: Phone  Email

Best time to contact by phone:

Vital Quote Information:

Male   Female    Age     Occupation:

Do you smoke: Yes  No    Height:  Feet   Inches  Weight:

Health Issues/Medical History: Please Indicate any current and past health conditions, hospitalizations or surgery (leave blank if none): --->
Medications: Please list any Prescription Drugs you have taken in the last year. --->  

Spouse:

Male   Female    Age     Occupation:

Do you smoke: Yes  No    Height:  Feet   Inches  Weight:

Health Issues/Medical History: Please Indicate any current and past health conditions, hospitalizations or surgery (leave blank if none): --->
Medications: Please list any Prescription Drugs you have taken in the last year. --->  

 

Child #1:

Male   Female    Age     Occupation:

Do you smoke: Yes  No    Height:  Feet   Inches  Weight:

 

Health Issues/Medical History: Please Indicate any current and past health conditions, hospitalizations or surgery (leave blank if none): --->
Medications: Please list any Prescription Drugs you have taken in the last year. --->  

Child #2:

Male   Female    Age     Occupation:

Do you smoke: Yes  No    Height:  Feet   Inches  Weight:

Health Issues/Medical History: Please Indicate any current and past health conditions, hospitalizations or surgery (leave blank if none): --->
Medications: Please list any Prescription Drugs you have taken in the last year. --->  

 

Child #3:

Male   Female    Age     Occupation:

Do you smoke: Yes  No    Height:  Feet   Inches  Weight:

 

Health Issues/Medical History: Please Indicate any current and past health conditions, hospitalizations or surgery (leave blank if none): --->
Medications: Please list any Prescription Drugs you have taken in the last year. --->  

Child #4:

Male   Female    Age     Occupation:

Do you smoke: Yes  No    Height:  Feet   Inches  Weight:

Health Issues/Medical History: Please Indicate any current and past health conditions, hospitalizations or surgery (leave blank if none): --->
Medications: Please list any Prescription Drugs you have taken in the last year. --->  

After you submit your info, you'll be taken to a page confirming it has been sent.

American Life & Health Group, Inc.
1013 Lucerne Ave. Suite 200
Lake Worth, Florida 33460

Email: info@amlifegroup.com
Call: (561) 547-9003
Toll-Free: (800) 426-2058
Fax: (561) 533-0391

Copyright 2006, American Life & Health Group, Inc.