Individual & Family Health

Our Health insurance companies are very competitively priced! By providing most major health insurance companies such as Blue Cross Blue Shield of Georgia, Coventry, Humana, Aetna, Consumers Life, and many more it affords us the ability to offer you the most coverage for the best price available. For a quote on individual or family health insurance please submit the form below. Please make sure to answer all questions to the best of your knowledge so we may accurately quote you.

Name *
Date of Birth*
Sex ----------- Male Female	Marital Status ----------- Single Married Divorced Widowed
Address *
City *   State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code *
Telephone *
Email *
Weight:*	Height:*
Any Use of Tobacco? ----------- Yes No
Please indicate any other dependants you wish to include on your policy and their most current information: (Name, Date of birth, Sex, Height, Weight, marital status, there address, and tobacco use.)
Is Anyone Currently Pregnant? ----------- Yes No
Are you interested in purchasing maternity insurance? ----------- Yes No
List all medications (dosage and frequency) taken within the past 12 months and the medical condition they were required for. Please make sure the prescription and medications for each dependant are clearly spelled
Are there any preexisting conditions for self or other dependants you are seeking coverage for?

The Insurance Source GA | Gary Reynolds and Associates INC 332 Washington St. NW | 206 Gainesville, GA 30501 Phone: 770-532-1900 | Toll Free: 1-877-532-4279 Fax: 770-532-2174

Hours: Monday - Friday 9:00am-5:00pm Appointments from 10:00am-4:00pm