Assurant Health One Deductible - Individual Quote Request
Thank you for your interest in the Assurant One Deductible Health Plan.  Simply complete this form and we will email you back with a No Obligation Quote.  If you like what you see, simply contact us at 1-800-544-9505.  We can answer any questions and begin the application process over the phone.  

Step 1: Contact Information
First Name:
Last Name:
State:
Zip Code:
Email Address:
Phone (Optional):

Step 2: Plan Information
Please Select Plan:
  • One Deductible means just that - The integrated annual deductible includes all covered expenses, including prescriptions.
  • The One Deductible PPO plan (lower rates) uses the PHCS PPO network. Search for providers by clicking here. Additional networks may be available for your area and will be included in your quote.
  • The One Deductible Traditional (non-PPO) does not restrict you to a network.
Payment Options:
Deductible Option:
Policy Limits:
Include Health Savings Account:

Step 3: Proposed Applicant Information
Applicant:

Age:

Step 4: Preferred Rating Questions
Please complete the following questions to determine eligibility for the Preferred or Preferred Smoker rating classes.  This information is necessary to provide an accurate quote.
QUESTIONS APPLICANT
1. Has the applicant used tobacco products at any time during the past 3 years? (if no, go to question 4.) Yes No
2. Does the applicant smoke 10 or more cigarettes per day? Yes No
3. Does the applicant smoke more than 1 cigar or pipe per day? Yes No
4. Is the applicant currently outside of the weight range in the build chart? Click Here Yes No
5. Has the applicant had blood pressure readings in excess of 140/90 in the past 12 months? Yes No
6. Has the applicant had total cholesterol readings above 220 and/or been treated for elevated cholesterol or triglycerides within the past 12 months? Yes No
7. Has the applicant had any convictions for DUI or more than 1 moving violation including speeding tickets within the past 2 years? Yes No

Important Notice: Long Term Consumer Care, Inc. realizes how important your privacy is.  The information that you have entered in this quote request will not be shared or sold to any third party.  Your information will only be used to provide you with a quote on the plan you have selected.  This is not an application for insurance and you are under no obligation to purchase insurance.  The Assurant One Deductible Health Plan is not available in AK, MA, NY, HI, ME, NH, NJ*, NY, VT or WA. (*only the state plan is offered)

I have read and understand the above statement.

Please include any additional comments: