Contacting Us Get A Quote Home
Return to Personal Insurance | Return to "Get a Quote" This form is for quoting Health Insurance. Fill this form out as completely as possible. The more information we have the more accurate the quote will be. Completion of this form does not bind coverage. Items with an must be filled in. Name: Email Address: Telephone: Street Address: City/State/Zipcode: --Select-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zipcode: County: --Select One-- Geauga Trumbull Lake Ashtabula Cuyahoga Summit Other... Other County: Contact Via: Select One Email Telephone US Mail Best Time to Contact: Select One Early Morning Late Morning Noon Early Afternoon Late Afternoon Evening Occupant Information: Date of Birth (xx/xx/xx) Height Weight Sex Tobacco Husband: Select One Male Female Select Yes No Wife: Select One Male Female Select Yes No Other 1: Select One Male Female Select Yes No Other 2: Select One Male Female Select Yes No Insurance Needs: Existing Health Insurer: Deductible Amount: Select One $250 $500 $1,000 $2,500 Doctor's Office Co-Pay: Prescription Drug Card: Select One Yes No Existing Medical Conditions or Prescriptions: Write as much as needed... How did you find us: --Select One-- Newspaper Phone Book Radio Referral Search Engine Television Web Site Personal Insurance Got A Question? Get A Quote Mail Payments to: The Frank Agency, Inc. P.O. Box 877 Middlefield, OH 44062-0877 Had An Accident: For an auto accident, please call the number on the back of your insurance card, then contact us with the details. For all other claims, please call us at 800-782-8328 so we can report the incident to your company. Need to Talk: 800-782-8328 Toll Free 440/632-5656 Personal Insurance | Commercial Insurance | Health Insurance | Financial Services | Investments | Get A Quote | Contacting Us The Frank Agency, Inc. • 15977 East High Street • Middlefield, Ohio 44062 • V: 440/632-5656 • F: 440/632-1859 • E: info@frankagency.com