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	Have questions regarding our international and domestic insurance services? Need a quote? Complete the form below to the best of your ability, and member of our staff will contact you shortly using the E-Mail address you provide below. Contact Name: E-Mail Address: State: -Select A State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Zip Code: Additional Questions: Please take a moment to provide us with some information about the adults (as well as any dependents) requesting information about our short-term insurance services. How long do you anticipate needing short-term health insurance? Select One 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months 12 Months 12+ Months Sex: Age: Date of Birth: (Month/Year) Select One Male Female / Select One Male Female / * Height/weight information only required for terms lasting more than 12 months. Number Of Dependents Thru 18: Male   Female Unmarried, Full-time Students Between The Ages Of 18 And 23: Male   Female Note To International Travelers: If you are requesting a quote and/or more information on international travel coverage, please answer the following questions. Are you a US citizen?: Select One Yes No How long do you plan to be out of your country of citizenship?: Select One 15 Days 1 Month 1 Month, 15 Days 2 Months 2 Months, 15 Days 3 Months 3 Months, 15 Days 4 Months 4 Months, 15 Days 5 Months 5 Months, 15 Days 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months 1 Year
	For additional information call me, Phil Mattox at 1-800-798-2890. Home | International Health Plans | Short-term Health Plans Basic Health/Dental Insurance | Legal | Contact Us © Phil Mattox Insurance Agency, All Rights Reserved. Adobe Acrobat Reader may be required to access PDF's on this site.