Contact Us:
Affordable Health Care LLC
Christina Muessig
Office: 636.931.9699 
Cell: 314.803.1838 · Fax: 636.547.2559
christinamuessig@gmail.com

 


In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name for RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross and Blue Shield Association.  ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 

Life & Disability

We would appreciate it if you would take a few moments to answer the following questions. Please be assured that we do not share or sell personal information about you except when we have your permission.
First Name
M.I.
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
Bold = Required field
Person To Be Insured
Date of birth
Gender
Height
Weight
Has this person used any tobacco products in the past 12 months?
Please list any health conditions that the person to be quoted has been diagnosed with (in the past 10 years). If you've listed anything, please provide date of onset, diagnosis, and current status:
Does this person take any medications?
If you answered Yes to medications, please list medication name, dosage and how it is taken:
Does this person have any immediate relatives who have ever had heart disease?
Does this person have any immediate relatives who have had any form of cancer?
Has this person been a U.S. or Canadian resident for at least 12 months?
Phone
E-mail
If life insurance, amount of death benefit:
Length of policy
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