We offer individual coverage and family health insurance and dental insurance policies through the following carriers:  HealthPartners, Blue Cross Blue Shield, Preferred One.  You can obtain a projection of an estimated cost, and coverage information based on your specific needs. This is not an application for health insurance. By completing the following information, clicking on the submit form at the bottom of the page.

If you would like information on Summary of Benefits and Rate Sheet for HealthPartners, please click on the HealthPartners logo below

Please note: Most carriers require an underwriting evaluation and approval of all prospective individual / family medical insurance policies

 

Sex: Male Female Date of Birth: -- mm/dd/yy format please Marital Status ? Single Married Coverage for Spouse ? No Yes If yes, Spouse birthdate:  -- mm/dd/yy If yes, number of children? Children to be covered? No Yes Occupation? Are you self-employed? No Yes Do you live in the Twin City 7 country Metro Area? Yes No If no, specify in which county: Your current health provider is? Your current health plan? Employee Sponsored Individual Under Cobra None of the above Which Plan(s) would you like information on? Volkman Insurance Agency L.L.C. has many different providers available for the individual / family. To make multiple selections hold down the "ctrl" key. Health Plans: HealthPartners BlueCross BlueShield of MN Preferred One Dental Plans: Landmark Dental Other If you are not sure which plan you would like, please complete the Plan preferences below. Plan Preferences: Please provide the following information, so that we may provide you with information on a plan that most closely fits your needs. Please select one answer for each question. Participating Physicians Choice Somewhat Important Not Important Very importmant Routine Physicals Somewhat Important Not Important Very importmant Maternity Coverage Somewhat Important Not Important Very importmant  Mail order Pharmacy Somewhat Important Not Important Very importmant Chiropractic Care Somewhat Important Not Important Very importmant Preventive Eye Examinations  Somewhat Important Not Important Very importmant Out of State of Minnesota Coverage Somewhat Important Not Important Very importmant Short term or Long term Coverage Long Term Short Term Personal Information: Name: Organization Street address Address (continued ) City State  MN Zip code  Phone Number Fax Number E-mail Which plan(s) would you like information on? Any pre-exististing health conditions per applicant ? No Yes If yes, please comment below Click on "Submit Form".  Please include either an e-mail address or phone number should any information be incomplete.

Individual / Family Plan Questionnaire Form

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