New Jersey Family Health Insurance Quote

In addition to New Jersey
Family Health Insurance,
we also offer affordable
Life Insurance policy
premiums or choose
another NJ family
insurance coverage from
the list below.

**Information received from this New Jersey Family Health Insurance quote

request form sent to American Insurance Services Agency 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 a New Jersey Health Insurance policy. We are licensed in New Jersey

and will not provide quotes for other states.

"Your Local New Jersey Family Health Insurance Policy Agent!"

We offer affordable New Jersey family health insurance policy premiums to residents of the

following NJ counties and cities: Union County, Essex County, Bergen

County, Passaic County, Sussex County, Morris County, Warren County,

Hunterdon County, Somerset County, Middlesex County, Monmouth County,

Mercer County, Burlington County, Clark, Newark, Jersey City, Elizabeth, Rahway,

Colonia, Iselin, Avenel, Woodbridge, Port Reading, Carteret, Perth Amboy, Fords,

South Amboy, Metuchen, Plainfield, Dunellen, South Plainfield, Green Brook,

Fanwood, North Plainfield, Cranford, Scotch Plains, Westfield, Union, Millburn,

Springfield, Mountainside, Gillette, Warren, Watchung, Stirling, Millington,

Middlesex, Martinsville, Piscataway, Edison, New Brunswick, Highland Park, North

Brunswick, Sayreville, East Brunswick, Somerset, Milltown, South River, Bound

Brook, Somerville, Bridgewater, Bayonne, Linden, Roselle, Hoboken, Union City,

Weehawken, West New York, Guttenberg, Cliffside Park, Edgewater, North Bergen,

Secaucus, Fairview, Ridgefield, Fort Lee, Leonia, Palisades Park, Englewood Cliffs,

Englewood, Bergenfield, Teaneck, Paramus, Bogota, Ridgefield Park, Little Ferry,

Hackensack, Maywood, Teterboro, South Hackensack, Rochelle Park, Moonache,

Lodi, Hasbrouck Heights, Saddle Brook, Garfield, Elmwood Park, Woodridge,

Carlstadt, East Rutherford, Lyndhurst, Rutherford, Wallington, Passaic, Clifton,

Paterson, Totowa, West Paterson, Little Falls, Great Notch, North Caldwell, Cedar

Grove, Verona, Montclair, Bloomfield, West Orange, Glen Ridge, Belleville, Nutley,

Kingsland, North Arlington, Kearney, Harrison, East Orange, East Newark, Orange,

Irvington, South Orange, Hillside, Townley, Livingston, Wayne, Trenton, Camden,

Atlantic City, Princeton, Vineland, Willingboro, and Toms River, NJ.

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:
Major Medical Health Insurance      Deductible Amount Desired:

Choose Benefit Options:
Individual or Family Dental Insurance Coverage:
Individual or Family Vision Insurance Coverage:

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 New Jersey Family Health insurance quote request.**

Applicant Information:

Family Health Insurance Coverage Desired:

Medical Information: