CT Health Insurance Quote

We offer affordable personal health insurance premiums from quality
insurance companies to residents in the following Connecticut counties
and cities: Fairfield County, New Haven County, Litchfield County,
Middlesex County, New London County, Hartford County, Tolland
County, Windham County, Stamford, Norwalk, Greenwich, Darien,
Riverside, Belltown, Springdale, Round Hill, Old Greenwich, East
Norwalk, New Canaan, Glenville, Byram, Cos Cob, Mianus, North
Stamford, Glenbrook, Wilton, Weston, Long Ridge, Noroton, West
Norwalk, Westport, High Ridge, Southport, North Wilton, Winnipauk,
Cannondale, Turn of River, South Wilton, Lyons Plains, Georgetown,
Ridgefield, Branchville, Redding, Topstone, Ridgebury, Redding Ridge,
Branchville, Dodgingtown, West Redding, Titicus, Hattertown, Bethel,
Danbury, New Fairfield, Newtown, Hawleyville, Botsford, Monroe,
Bridgeport, Stepney, Shelton, Huntington, Upper Stepney, Long Hill,
Trumbull, Stratford, Easton, Fairfield, Greenfield Hill, Stratfield, Nichols,
Oronoque, Rivercliff, Devon, Lordship, and East Bridgeport, New
Haven, Hartford, Torrington, Waterbury, Meriden, New Britain, New
London, Norwich, Manchester, East Hartford, Suffield, Granby, West
Haven, West Hartford, Branford, East Haven, Hamden, Woodbridge,
Orange, North Haven, Groton, Rocky Hill, Newington, Wethersfield,
Glastonbury, Bloomfield, Blue Hills, South Windsor, Naugatuck, New
Hartford, Chesire, East Lyme, Old Mystic, Wallingford, Southington,
Middletown, Bristol, Laurel Beach, Litchfield, Pleasure Beach, Mystic,
North Westchester, Double Beach, Willimantic, Storrs, Canaan, East
Windsor, Vernon, South Canaan, Putnam, Guilford, Windham, South
Britain, Willington, Windsor, East Hampton, Brooklyn, and Westchester,
CT.

Information received from this Connecticut family health insurance quote form sent to Stamford
Insurance Group will be for our use only and will not be sold, given to or distributed to any other
parties. A quote will be based on the health insurance information provided and does not
guarantee acceptance of the risk by us. The precise coverage afforded is subject to meeting
underwriting guidelines, and the terms, conditions and exclusions of the policy as issued. By
submitting this request you acknowledge that this is neither an offer to insure nor a guarantee of
insurance. Completion of this form does not entitle you to Connecticut personal health insurance.
We are licensed in Connecticut, New York, New Jersey, Massachusetts, and Rhode Island. We will
not provide quotes for other states.

Full Name:
Home Address:
City:     State:     Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?

Do you currently have health insurance?
Type of health insurance currently owned:
Current Premium:$ per month

Family Health Insurance Coverage For:
How many children to be insured?

HMO Health Insurance   HMO Co-Pay Amount Desired:
PPO Health Insurance     PPO Deductible Amount Desired:
POS Health Insurance     POS Co-Pay Amount Desired:

Choose Benefit Options:
Individual or Family Dental Insurance Coverage:
Individual or Family Vision Insurance Coverage:
Are you interested in only Temporary Insurance Coverage?
Length of Temporary Coverage Needed:

Within the last 2 years have you or any person to be insured been aware of, diagnosed
and /or been treated by a member of the medical profession for: heart disease or
disorder, stroke, cancer, diabetes, drug or alcohol dependency, mental disorder,
emphysema, airway or pulmonary disease, crohn's disease or ulcerative colitis,
nervous system disorder, liver disorder, kidney disorder, crippling or disabling
arthritis, spinal disc disease, knee or hip disorders?

If "Yes", please list information below.

Have you or any person to be insured been hospitalized
within the past 12 month, due to be so confined or been
disabled for more than 5 days within the past 12 months?

If "Yes", please list information below.

During the last 5 years have you or any person to be insured been diagnosed by a
member of the medical profession as having Acquired Immune Deficiency Syndrome
(AIDS) or AIDS related complex (ARC) or tested positive for HIV?

If "Yes", please list information below

Additional Information or Comments

Click on the "Submit Quote Information" button below to send
your Connecticut Family Health insurance quote request.