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INFORMATION ABOUT OUR INSURANCE PLANS
 LIFE INSURANCE - INDIVIDUAL HEALTH INSURANCE - GROUP HEALTH INSURANCE - LONG TERM CARE - ANNUITIES
 MEDICARE SUPPLEMENTAL INSURANCE - GAP SUPPLEMENTAL INSURANCE

REQUEST A FREE INSURANCE QUOTE
  Individual Health Insurance - Group Health Insurance - Life Insurance - GAP Supplemental Insurance - Medicare Supplemental Insurance -  Annuities
 We also offer: Dental Insurance, Vision Insurance, Short Term Medical Insurance and Overseas Travel Insurance

Free Health Insurance Quotation
for Individuals and Families
Please complete this one page
Health Insurance Quotation Request Form

Name

 

Address

 

City

 

State

Louisiana

 

Zip Code

 

E-Mail Address

 

Phone Number

 

Date of Birth

 

Have you used tobacco in any
form in the last 12 months?

Yes

No

 

Your Height

feet

inches

 

Your Weight

pounds

 

List any medical conditions treated for in the last 5 years?

 

If medication taken, what prescription and for what condition?

 

Currently insured by
which insurance company?

 

Type of Coverage Desired

 

Company Desired

 

Deductible Desired

 Please Complete the Following Information
For All Other Family Members to be Insured.

1st Additional Family Member to be Insured

Name

 

Date of Birth

 

Height

feet

inches

 

Weight

pounds

 

Has this family member used tobacco
in any form in the last 12 months?

Yes

No

 

List any medical conditions treated for in the last 5 years?

 

If medication taken, what prescription and for what condition?

2nd Additional Family Member to be Insured

Name

 

Date of Birth

 

Height

feet

inches

 

Weight

pounds

 

Has this family member used tobacco
in any form in the last 12 months?

Yes

No

 

List any medical conditions treated for in the last 5 years?

 

If medication taken, what prescription and for what condition?

 3rd Additional Family Member to be Insured

Name

 

Date of Birth

 

Height

feet

inches

 

Weight

pounds

 

Has this family member used tobacco
in any form in the last 12 months?

Yes

No

 

List any medical conditions treated for in the last 5 years?

 

If medication taken, what prescription and for what condition?

 4th Additional Family Member to be Insured

Name

 

Date of Birth

 

Height

feet

inches

 

Weight

pounds

 

Has this family member used tobacco
in any form in the last 12 months?

Yes

No

 

List any medical conditions treated for in the last 5 years?

 

If medication taken, what prescription and for what condition?

 If you have more family members you wish to insure, please list their names below and we will contact you for more information.

Are you interested in Dental Insurance?

Yes

No

How would you like to receive your
Health Insurance Coverage Information?

By phone

By e-mail

By fax

 

If by Fax, Enter Fax Number

Comments or Questions

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Landeche Insurance, LLC
2000 Neely Street; Jefferson, LA 70121

Phone: 504-228-7184
Fax: 504-252-9923
We are here to help!

E-mail: info@landecheinsurance.com

Landeche Insurance, LLC provides individual health insurance, group health insurance, life insurance, dental insurance, vision insurance, GAP supplemental insurance, Medicare Supplemental Insurance and annuities to New Orleans, Metairie, Kenner, Harahan, Jefferson Parish and all surrounding areas in Louisiana.

©2011 Landeche Insurance, LLC

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