WE RESPECT YOUR PRIVACY

Your privacy is important to us. Waguespack Insurance considers the protection of your personal information to be a primary goal. We respect your right to keep your personal information confidential.

We collect information in order to quote and service your insurance policy. This information is used only by our company and is not shared with any other vendor from which you could receive a solicitation.

Waguespack & Associates uses Secure Sockets Layer (SSL) protocol to interact with you when you provide personal information during the purchase and payment processes. We handle your information via 64-bit encryption. Every secure page has been secured with a digital certificate generated by COMODO Security. To view this certificate, click on the image of the "closed lock" or the "solid key" on the bottom of your browser window. A small frame displaying site security information will appear.

AS AN INDEPENDENT INSURANCE AGENCY...

we do not work for an insurance company; we work for you. We work on your side when you have a loss and follow through to see that you get a fair, prompt payment.

 

 
Health Insurance Quote Form
To request a quote, please complete the form as completely as possible. If currently insured, your policy's declaration page will have much of the needed information. Type "unsure" in any required field in which you aren't sure of the answer. Your information will be forwarded to our agents, and all information is transferred securely and will be kept confidential.


Contact Information
Name
Street address
City
State
Zip Code
Daytime Phone
Evening Phone
FAX
E-mail Address

Insurance Policy Information
Are you currently insured? CHECK ONE Yes        No*
*If No, please give reason not insured currently. i.e.: First time insured, policy canceled 3 mo's ago, etc.
If yes, by what company?
Policy expiration date?
Length of time continuously insured
 

Requestor's Information
 

Applicant

Spouse
(only complete if applicable)
Gender

Male Female

Male Female
Date of birth

mm/dd/yy

mm/dd/yy
Smoked in the last 12 months?

Yes No

Yes No

Coverage Options
Dependent Coverage Required?
# of Children
*Maternity Coverage? Yes No
 Maternity coverage is mandatory in some states, so if you are not sure, are female and are still of child bearing age, leave yes checked.
Is applicant or  spouse currently pregnant?
Yes No Not Applicable

Optional Coverage

Please select any options you would like included in the quotes.
Co-payments Prescription Card Vision Care
Wellness Coverage Dental

Optional Coverage Comments

 

Provide any additional information or comments below.