This form collects some basic information necessary for a Certus Health Licensed Healthcare Consultant to determine your best health coverage options and your insurance premium quotes. The licensed healthcare consultant will contact you by e-mail first, and then by phone to make sure that all your questions are answered.

This consultation is absolutely FREE and there is NO obligation on your part to act upon our recommendations. Finally, if you prefer to call our call center and talk live to a licensed healthcare consultant, please call 832.239.5444 between 8:30 AM and 5:30 PM, Monday-Friday, and we will take your information over the phone.

CERTUS HEALTH WILL NOT DISCLOSE, GIVE, SELL OR TRANSFER ANY PERSONAL INFORMATION YOU GIVE TO US TO UNRELATED THIRD PARTIES, UNLESS REQUIRED BY JUDICIAL ORDER OR STATUTE. WE DO NOT SHARE PROTECTED HEALTH INFORMATION (PHI) WITH UNLICENSED AFFILIATES OR ASSOCIATES. Read more about our Notice of Privacy Practices.

Applicant(s)

First Name * Gender (M or F) * Date of Birth (MM/DD/YY) * Tobacco use in last 12 months? (Y or N) * Full-Time College Student? * Height * Weight (lbs) * Pre-existing conditions? (Y or N) Applicant M   F Y   N Y   N Y   N Dependent #1 M   F Y   N Y   N Y   N Dependent #2 M   F Y   N Y   N Y   N Dependent #3 M   F Y   N Y   N Y   N Dependent #4 M   F Y   N Y   N Y   N Dependent #5 M   F Y   N Y   N Y   N Dependent #6 M   F Y   N Y   N Y   N

Contact Information

* Name * E-Mail * Phone State * Zip Code

Current Insurance Information (For comparison purposes ONLY)

Current Insurance Carrier Monthly Premium Annual Deductible Annual Out of Pocket Maximum Maximum Lifetime Coverage

How did you hear about Certus Health?

TV Commercial Which channel? Clinic or Doctor’s Office Which clinic or doctor’s office? Friend Which friend? Internet Search Which search engine?