Please complete the following form and submit to Buffalo Agency to receive a free comprehensive health quote.  A Health Insurance specialist will contact you from the Buffalo Agency.

Per Our Privacy Policy, we will never sell  your personal information to a third party. All information is confidential and for the sole use of Buffalo Insurance to provide your quote.

HEALTH INSURANCE QUOTE

Are you currently working with an agent? * Todd Parker I have not spoken to an Agent yet

PRIMARY ADULT INFORMATION

Last Name *

First Name *

Street Address

City *

State * AR OK TN TX

Zip Code *

Primary Phone Number *

Secondary Phone Number

EMAIL *

RE-ENTER EMAIL *

Date of Birth (Month/Year) * 00/00/0000 - - Choose One - - January February March April May June July August September October November December

Year *

GENDER * MALE FEMALE

Height * Ft-Inches

Weight *

Tobbaco Usage? * Yes No

SPOUSE INFORMATION - (Complete only if Interested in Family Plan)

Last Name

First Name

Date of Birth (Month/Year) 00/00/0000 - - Choose One - - January February March April May June July August September October November December

Year

GENDER MALE FEMALE

Height Ft-Inches

Weight

Tobbaco Usage? Yes No

DEPENDENT CHILDREN TO BE COVERED

Number of Children to be covered:

Ages (Separate with a comma)

HOW ELSE CAN WE HELP YOU TODAY?

Some of our clients have saved over 20% on their auto and home insurance by letting us shop for a better rate or by combining their coverages.

Would you like us to see if we can save you money on your AUTO insurance? * YES NO

Would you like to see if we can save you money on your HOME insurance? * YES NO

Do you need a LONG TERM CARE insurance quote? * YES NO

Do you need a Life Insurance quote? * YES NO

Are you interested in adding Supplemental Insurance for Cancer or Disability Benefits? * YES NO

Security Code *