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3201 N. Atlantic Ave.Cocoa Beach , FL
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Get a Quote

Life's twists and turns can make preparing for the unexpected especially daunting. Let the experienced agents at Brevard Insurance & Marketing alleviate the burden of ensuring your family's well-being. No matter what stage of life or situation you face, we offer a variety of life and helath insurance products to offer peace of mind and sound coverage for your family.

Navigating your health insurance options and needs are ever-changing and increasingly more complex. That's why the knowledgeable agents at Brevard Insurance & Marketing can help you determine the best coverage for you and your family. Rest assured, our vast network of carriers and dedication to customer service will afford your family a variety of life and health insurance products to choose and offer peace of mind and sound coverage.

To get a rate quote directly from our associate insurance companies, Humana or United Health One, please click the images below to be connected directly to their site. To get a quote from other insurance companies, please fill out the form below.

humana - get a quote/apply united health one - get a quote




Personal Information

Name: Email:
Address: Day Phone:
City: Night Phone:
State: Best time to call:
Zip: Preferred Contact Method: Email   Phone

Information About Yourself And Family

  Self Spouse Child #1 Child #2 Child #3
Name:
Date of Birth:
Sex: M   F M   F M   F M   F M   F
Marital Status: M   S M   S M   S M   S M   S
Occupation:
Height: ft. in. ft. in. ft. in. ft. in. ft. in.
Weight: lbs. lbs. lbs. lbs. lbs.
Have you (they) had any of the following health conditions:
  Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP
Heart
Cancer
Diabetes
HBP

Information About Yourself And Family

**quit -- Please enter information if any to be insured are FORMER TOBACCO users.
**quit Month/Year:
Packs per day:
Years smoked?:


Individual Histories

Please list any individual histories on each person to be covered.

Self: Is person to be insured currently on any prescription medications for ongoing health conditions?

If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Yes   No
Spouse: Is person to be insured currently on any prescription medications for ongoing health conditions?

If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Yes   No
Child #1: Is person to be insured currently on any prescription medications for ongoing health conditions?

If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Yes   No
Child #2: Is person to be insured currently on any prescription medications for ongoing health conditions?

If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Yes   No
Child #3: Is person to be insured currently on any prescription medications for ongoing health conditions?

If yes, please list below. Also, please DISCLOSE any and all health conditions they have (or had in the past):
Yes   No


Life Coverages

  Self Spouse Child #1 Child #2 Child #3
Amount of
Coverage:
$ $ $ $ $
Type of
Coverage:
Term
Whole
Universal
Term
Whole
Universal
Term
Whole
Universal
Term
Whole
Universal
Term
Whole
Universal
Term Length (Optional)
Disability
Income:
Y   N Y   N N/A N/A N/A
Long Term
Care:
Y   N Y   N N/A N/A N/A

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional children or other information where there was not enough space, please enter them here.

Please click on the "Send Form" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

Submission of quote request form to this agency does not constitute a binding confirmation of new or revised insurance coverage.

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