Skyline Insurance Services Pennsylvania residents call (570) 623-3000 New York residents call (800) 258-9404
Health Insurance
Individual Health Insurance Quote for NY Residents (PA Residents Click Here)
This application shall not be binding on the Underwriters unless and until a contract of insurance is issued and delivered in accordance herewith and then only as the commencement date of said insurance and in accordance with all terms thereof. The Applicant hereby covenants and agrees to and with the Underwriters that the foregoing statements and answers fully and truly represent, to the best of the Applicant's knowledge, all the facts and circumstances with regard to the risk to be insured. The Applicant also agrees that the answers and statements contained herein form the basis and conditions of the insurance.

The Applicant understands that the application can't be signed.
About You (*indicates required field)
* :
*
* *
* *
* Please Enter Email
* Please Enter EmailEmail addresses don't match.
*  
Health Information:
Do you currently have Health insurance?   *
If yes, when does your policy expire?
Are you, your spouse or any dependents now pregnant?   *
Have you shown any signs of cardiovascular disease?
*
Do you have any pre-existing medical conditions?   *
If yes explain:
Do you currently take any medications?   *
If yes, list medications:
Include Spouse in Quote?   *
Additional Information:
  About You Your Spouse
Gender:

Date of Birth:
Height & Weight:
Tobacco Use:
Children
List children that need to be included in the quote below.
Child #1 Child #2
DOB DOB
Child #3 Child #4
DOB DOB
Child #5 Child #6
DOB DOB
Optional Coverage: (check any that you may want)





Questions/Comments: