Health Insurance PPO
As a member of a PPO (Preferred Provider Organization) plan
will be encouraged to use the insurance company's network of
preferred doctors and hospitals. This mean that you can
choose a doctor or hospital from PPO contracted to doctors
and hospitals.

You will have an annual deductible to pay before the insurance
company starts covering your medical bills. You may also have
a co-payment for certain services or be required to cover a
certain percentage of the total charges for your medical bills.

With a PPO plan, if you choose a doctor or hospital  
out-of-network physician are typically covered at a lower
percentage than services rendered by a network physician.

Please fill the form and an agent will contact you to offer you
different insurance options.
Your name:
Address:
City:
Zip Code:
Daytime Phone:
Evening Phone;
Your email address:
Have you used tobacco or nicotine products in the past 12 month?
No
Yes
Have you used tobacco or nicotine products in the past 18 month?
Yes
No
Is anyone included in this request pregnant?
Yes
No
Has anyone been treated by a doctor for a major health condition in the past year?
Yes
No
Has any one been hospitalized in the past 5 years?
Yes
No
Has anyone been denied coverage in the past year?
Yes
No
Are you self employed?
No
Yes
Do you currently have health insurance?
Yes
No
Does anyone take prescription medications?
Gender
Weight
Famle
Male
Birthdate
Adeeb Barsoum: Broker 480-205-5553