Riedmiller & Associates - Employee benefits with you, for you - with Employee Benefits Programs, Individual Insurance and Health Savings Accounts
Contact Us: Quote Request Form

Do you want more affordable health insurance? Looking for an affordable alternative to the insurance offered by your employer? Are you self-employed? In school? Between Don't get health insurance through your employer? Need dependent coverage?

Insurance for One™ may be just the coverage for you and your family. At a price you can afford. Find out what our clients say about Insurance for One.

It's easy to get a free, no obligation quote—and a choice of carriers. Please provide some information below about your needs. We will identify the carriers (not just one or two) and coverage that fit your need and will help protect you and your family from the financial hardship of unexpected illness and injuries. We will contact you promptly if we need more information to provide you with the most accurate quotes.

We respect your privacy, and assure you that we will keep confidential any personal information as specified in our Privacy Policy.

Please complete the following:

(*required information)
First Name*
Middle Name
Last Name*
Date of Birth* (mm/dd/yyyy)
Gender*

Male

Female

Address 1
Address 2
City*
State*
Zip Code*
Email*
Phone*
Fax
Type of Coverage:

Individual or Family Coverage
(health care coverage for more than 6 months)

Individual or Family Coverage - Short Term
(health care coverage for less than 6 months)

Medicare eligible
(eligible for Medicare and need coverage options)


Start of Coverage:

On what date should coverage begin?* (mm/dd/yyyy)

Family Members:

Please include only those family members for whom you want coverage. If you want coverage for dependent children only, enter the oldest child as the applicant.

   

Gender

Date of Birth (mm/dd/yyyy)

Check if Tobacco User

Check if Student

Applicant

 

Male

Female

Spouse

 

Male

Female

Child

 

Male

Female

Child

 

Male

Female

Child

 

Male

Female

Child

 

Male

Female

Child

 

Male

Female

Child

 

Male

Female

Preferred Contact Method:

Phone

E-mail

US Mail

When is the best time to contact you?

9am - Noon

1 - 4 pm

4 - 7 pm

How did you hear about us?
Friend
Online Ad
Print Ad
Search Engine

Other
 
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Thank you for your request!

NOTICE: The use of the information you provide to us is governed by the Terms of Use and Privacy Policy posted to this website. By completing this form and clicking on the "Submit" button below, you acknowledge that you have read and accept the Terms of Use and Privacy Policy.

 

Riedmiller & Associates, Inc.   1-800-422-7844

 

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