NH Health Insurance Quote

We are your local southeastern New Hampshire, southern Maine
insurance agency, offering affordable health insurance policy premiums
in the following cities and counties: Somersworth, Durham, Portsmouth,
Dover, Rochester, Rollinsford, Barrington, Madbury, Lee, Strafford,
Farmington, Milton, Barnstead, Nottingham, Northwood, Raymond,
Newmarket, Newfields, Stratham, Rye, Hampton, Epping, Exeter,
Salem, Danville, Deerfield, West Rye, Derry, Chichester, South
Barnstead, Gilmanton, New Durham, Wolfeboro, Alton, Laconia, Berlin,
Lebanon, East Candia, North Hampton, Hanover, Littleton, Plymouth,
Claremont, Newport, Keene, Hampton, Rye Beach, Strafford County,
Rockingham County, Hillsborough County, Merrimack County, and
Belknap County, NH. We also offer health insurance policy services
throughout the state of New Hampshire, including the Manchester,
Nashua, and Concord area. Our service area in southern Maine includes
the following cities and counties: South Lebanon, Kittery, Eliot,
Berwick, Sanford, Blaisdell Corners, Springvale, Emery Mills, Wells
Beach, York Beach, Kittery Point, Kennebunk, Saco, Biddeford, Alfred,
Portland, Scarborough, Westbrook, Waterboro, Shapleigh, Newfield,
Buxton, Goodwins Mills, South Sanford, Cape Elizabeth, South
Portland, York County, and Cumberland County, ME.

Full Name:
Home Address:
City:
State: (New Hampshire or Maine)
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:
Age of Spouse:
How many children to be insured:

New Hampshire Family or Individual Health Insurance Coverage Desired:

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:
Life Insurance Coverage:

Medical Information:

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 Hampshire Health Insurance quote request.**

**Information received from this New Hampshire Health Insurance quote request form sent to Gorman Insurance and Risk Management Services, 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 family or individual health insurance policy 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 Hampshire Health Insurance Policy. We are licensed in New Hampshire and Maine, and will not provide quotes for other states.