Applicant Information

First Name:

Last Name:

Address:

City:

SOUTH CAROLINA

Zip Code:

Daytime Phone:

Cell Phone:


Email:  (Required)


How Best To Contact You:


Currently Insured:


Date of Birth:

Gender:

Height:

Weight:


Do You Smoke:


Age of Spouse:



Currently Own Health Insurance:


Type of Health Insurance Owned:


How Many Children to Insure:




Choose Coverage and Limits

Health Insurance Coverage For:



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

Major Medical Deductible Desired:




Choose Additional Benefit Options

Dental Insurance

Vision Insurance

Life Insurance



Medical Information

Within the last 10 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 serious health
problem(s) below:





During the last 10 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?





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 explain below:





Question or Message:




Click the "Submit Quote Request"
button below to send your South
Carolina Health Insurance request
to Russell-Massey & Company.


***By submitting this request you
acknowledge that this is neither
an offer to insure nor a guarantee
of insurance.***








We are a Columbia, SC insurance
agency offering affordable South
Carolina health insurance quotes
in the following towns, cities and
counties in South Carolina:
Chapin, Arthurtown, Saluda, Terrace,
Sandwood, Arcadia Lakes, Cayce,
Olympia, Forest Acres, Dentsville,
Eau Claire, West Columbia, Springdale,
Denny Terrace, Belmont, St. Andrews,
Irmo, Oak Grove, Lexington, Galaxy,
Bluff Estates, Hazelwood Acres, State
Park, Haskell Heights, Lincolnshire,
Ballentine, Killian, Red Bank, South
Congaree, Edmund, Gilbert, Summit,
Gaston, Hopkins, Capitol View, Horrel
Hill, Fort Jackson, Pontiac, Elgin,
Blythewood, Camden, Richtex,
Whitehall, White Rock, Sumter, Lugoff,
Boykin, Rembert, Hagood, Horatio,
Stateburg, Borden, Wedgefield, Oswego,
Gadsden, Fort Motte, St. Matthews,
Swansea, Woodford, Winnsboro, Pelion,
Steedman, Samaria, Monetta,
Batesburg-Leesville, Stoney Hill,
Prosperity, Newberry, Peak, Little
Mountain, Slighs, Pomaria, Jenkinsville,
Rion, Winnsboro Mills, Simpson,
Smallwood, Ridgeway, Orangeburg,
Lexington County, Fairfield County,
Calhoun County, Sumter County,
Kershaw County, Saluda County,
and Richland County, SC. We can
also offer a South Carolina health
insurance quote throughout the Palmetto
state, including in Florence, Greenville,
Spartanburg, Myrtle Beach, and
Charleston, SC.
Health
Insurance Quote
& Company, Inc.
General Insurance
Russell-Massey
800-849-7475
803-779-7854
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Russell-Massey & Company, Inc.
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