Full Name:          
Home Address:
City:
State:  FLORIDA
Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You:       Cell Phone:
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:         

Florida 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 Florida Health Insurance quote request.**


**Information received from this Florida Health Insurance quote request form
sent to FCI Insurance Agency 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 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 Florida Health Insurance policy. We are licensed
in Florida and will not provide health insurance quotes for other states.


Florida Family or Individual
Health Insurance Quote
We are a Davie, FL insurance agency offering affordable Florida family health
insurance quotes to residents of the following cities and counties: Coral
Springs, Fort Lauderdale, Parkland, Coconut Creek, Margate, North
Lauderdale, Lighthouse Point, Hillsboro Beach, Deerfield Beach, Boca
Raton, The Hamptons, Highland Beach, Weston, Plantation, Playland Isles,
Melrose Park, Lauderhill, Sunrise, Tamarac, Wilton Manors, Oakland Park,
Lauderdale Lakes, Sea Ranch Lakes, Villages of Oriole, Pompano Beach,
Lauderdale-by-the-Sea, Boca West, Delray Beach, Boca Pointe, Boynton
Beach, Lantana, Rainbow Lakes, Atlantis, Lake Worth, Miami, South Palm
Beach, Palm Springs, Greenacres, Wellington, Haverhill, Palm Beach,
Golden Lakes, Riviera Beach, Glen Ridge, West Palm Beach, Lake Park,
Royal Palm Beach, Jupiter, Juno Beach, North Palm Beach, Loxahatchee,
Belle Glade, Palm Beach Shores, South Miami, Cutler Ridge, Princeton,
Perrine, Naranja, Homestead, Florida City, Leisure City, Richmond Heights,
Pinecrest, Howard, Coral Way Village, Westchester, Westwood Lakes,
Brownsville, Sweetwater, Key Biscayne, North Bay Village, Miami Beach,
Miami Springs, Virginia Gardens, Hialeah, El Portal, Miami Shores, Medley,
Indian Creek, Surfside, Bal Harbour, North Miami, Biscayne Park, Pinewood
Park, Opa Locka, Bunche Park, Hialeah Gardens, Palm Springs North,
Carol City, Norland, Ojus, Miami Lakes, Biscayne Gardens, Hallandale,
Sunny Isles Beach, Golden Beach, Aventura, Uleta, Miramar, Pembroke
Pines, North Miami Beach, Hallandale Beach, Ives Estates, Pembroke Park,
Coral Gables, Kendall, Dania Beach, Cooper City, West Miami, Hollywood,
Broward County, Palm Beach County, and Miami-Dade County, FL. We can
also offer affordable Florida health insurance quotes throughout the Sunshine
state, including in Orlando, Tampa, St. Petersburg, Sarasota, Tallahassee,
Gainesville, and Jacksonville, FL.
FCI Insurance
Agency of Davie, FL
offers affordable and
experienced personal
insurance coverage
services throughout
Florida.
Contact us about
Florida Auto, Renters,
Homeowners, Health,
Motorcycle, RV, and
Flood Insurance at
(954) 434-6515.

In addition to Florida
Health Insurance
quotes, we also offer
affordable Home
Insurance policy
premium quotes.
Applicant Information:
We can assist you with Florida Family Health
Insurance policy coverage throughout south Florida!
Your Florida Health
Insurance Source
FCI Insurance Agency
& Auto Tag Service
8230 Griffin Road
Davie, Florida 33328
Broward County FL
(954) 434-6515
Fax: (954) 434-6524

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