Cory Keifer
Phone: (317)776-6770
Fax: (317) 776-6780
Email: cory@gordonmarketing.com		  

Get a FREE Quote Today!

Real Major Medical Insurance

  • Individuals
  • Small Businesses
  • Pre-existing Conditions
  • Coverage on the First Day (No Waiting Period)
  • Doctor & Drug Co-pays
  • Coverage to $25 Million
  • No Referrals Necessary
  • Short Term Coverage
Zip Code:
   
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Now offering coverage for pre-existing conditions.

Free Phone Consultations

317-776-6770

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Panel 1

Cory Keifer
Phone: (317)776-6770
Fax: (317) 776-6780
Email: cory@gordonmarketing.com

Get a FREE Quote Today!
First Name:
Last Name
Email Address
Daytime Phone
Evening Phone
Fax:
Occupation:
Address:
Address Line 2:
City:
State:
Zip Code:
 

Continue

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Panel 2

Cory Keifer
Phone: (317)776-6770
Fax: (317) 776-6780
Email: cory@gordonmarketing.com

 

Get a FREE Quote Today!
  Gender Date of Birth (dd/mm/yyyy) Height Weight Tobacco User Medication
Applicant::

/   /

ft in

lbs

No  Yes 

No Yes
Spouse:

/   /

ft in

lbs

 No  Yes  No Yes
Children:

/   /

ft in

lbs

 No  Yes  No Yes
 

/   /

ft in

lbs

 No  Yes  No Yes
 

/   /

ft in

lbs

 No  Yes  No Yes

Continue

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Panel 3

Cory Keifer
Phone: (317)776-6770
Fax: (317) 776-6780
Email: cory@gordonmarketing.com

 

Get a FREE Quote Today!
Current Insurance Carrier: (type "none" if no current coverage)
Current Premium (if applicable)
When does your coverage expire? / (mm/yyyy)
Describe any medical problems you, your spouse, or children have experienced within the last 5 years:

I am also interested in: (Check all that apply)

Life Insurance

HSA (Health Savings Account) Health Plans

Medicare Plans and Part D

Dental Coverage
Is the information entered correct?    If correct enter "YES"

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