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Individual & Family Health Insurance Instant Quote

	Individual & Family Plans		Dental Plans		Child Only Plans		Medicare Plans

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	Gender	Age	Tobacco User ?	Full-time Student?
Applicant:
Spouse:
Child:
Child:
Child:
Child:
Child:
* Child under one year: use age "0"

Requested Effective Date:

March April May

Medical Plan Type
	Standard Individual & Family Coverage
	Short-Term, Up to 12 Months of Temporary Coverage

California Health Plans, a division of Dave Terpening Insurance Agency, Inc. | 22850 Crenshaw Blvd. #206 | Torrance, CA 90505

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