Campbell & Associates Insurance, Inc.

If you are requesting a quote, it requires that you complete the following survey as completely and accurately as possible. Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for quote purposes only. If you prefer, you may contact us directly. We look forward to serving you.

Contact Information

City:  State:  
Work Phone Number:
Home Phone Number:
 Fax Number: 
Email Address:

Quote Information

Date of Birth: / /
Gender: Male   Female
Smoker?: Yes   No
Height & Weight: (ex: 5' 8")
(ex: 150 lbs)
Daily Benefit ($50 - $500):
Waiting Period (0 - 365):
Benefit Period: Lifetime
3 years or more
12 to 35 months
Include Home Health Care Coverage?: No   Yes
Include Compound Inflation Rider Coverage?: No   Yes
Please describe any and all health conditions that resulted in hospitalization and/or surgery in the past 10 years:

Spouse/Companion Information

Relationship?: Spouse   Companion
Gender: Male   Female
Date of Birth: / /

Additional Considerations/Requests

Please give any additional comments you feel appropriate for this quotation.
Please click on the "Submit Request" button to send us your quote request.