Welcome to Young's Insurance

Request A Quote

Thank you for your interest in our services. If you are only looking for information on your PART D Prescription Plan
and want us to run your prescriptions for you, check out our Part D Prescription Page. If you're interested in group coverage,
please contact us and we'll be happy to discuss your needs. If you're interested in Aetna US Healthcare, please click here to
apply online for a quote directly from their site Aetna US Healthcare. If you are specifically looking for short term, student and
Health Savings Accounts (HSA) through Assurant Health, click below to submit your request directly from their site. If you'd like
information on other products or you aren't sure which products or carriers you're interested in and would like an agent to contact
you, please fill out the information below. One of our agents will be in touch with you to discuss coverage options.

For a quote from either Aetna or Assurant click on their logo below:

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Mailing Address (If Different from Above)

Address 1

Address 2

City

State

Zip Code

Home Phone

Work Phone

Email Address

How would you like to be contacted?

                                                  How did you hear about Young's Insurance Services?
                                            If you can give us details we will be able to thank the referrer
                                               and make sure your quote goes to the correct agent.

Details...

What type of coverage are you looking for?

Occupation

Marital Status

Please supply the following information for each person you would like to be covered.

Applicant

Date of Birth

Gender

Height

ft in

Weight

Zip Code of Residence

Citizenship

Spouse or Dependent #1 - Click here if no more dependents

Date of Birth

Gender

Height

ft in

Weight

Zip Code of Residence

Citizenship

Dependent #2 - Click here if no more dependents

Date of Birth

Gender

Height

ft in

Weight

Zip Code of Residence

Citizenship

Dependent #3 - Click here if no more dependents

Date of Birth

Gender

Height

ft in

Weight

Zip Code of Residence

Citizenship

Dependent #4 - Click here if no more dependents

Date of Birth

Gender

Height

ft in

Weight

Zip Code of Residence

Citizenship

Dependent #5 - Click here if no more dependents

Date of Birth

Gender

Height

ft in

Weight

Zip Code of Residence

Citizenship

Dependent #6- Click here if no more dependents

Date of Birth

Gender

Height

ft in

Weight

Zip Code of Residence:

Citizenship

Please indicate below the products in which you're interested.

Individual Health Insurance
Group Health Insurance
Disability Insurance
Medicare Supplement (Medigap)
Medicare Prescription Plans (Part D)
Medicare Advantage Plans
Dental Insurance
Long Term Care
Short Term Care
Term Life
Whole Life
Mortgage Insurance
Universal Life Insurance
Final Expense Plans
Annuities

Please check below to indicate if this is a new enrollment

New Enrollment
Change Enrollment
Rate Review

Are you eligible for benefits from your employer?
Are you a sole proprietor or are you self-employed?
Do you currently have coverage?
Do your spouse and/or children currently have coverage?
Name of current or most recent coverage provider
Date of termination of coverage if applicable

Have you, your spouse or any of your dependents ever filed a claim or received benefits from disability or workman's comp?
Are you, your spouse or any of your dependents eligible for Medicare?
Have you, your spouse or any of your dependents ever been declined, postponed, had a waiver applied or been charged an additional premium for life, health or disability insurance or had any such insurance rescinded?
Please give us your comments or additional information on the above

Please check below if any of the following apply to any applicant.
	AIDS & AIDS related	Epilepsy	Liver disease
	Psychiatric disorders	Alcoholism	Fatigue disorders
	Lupus	Rheumatoid arthritis	Alzheimer's
	Heart Disease / Bypass surgery	Lymphoma	Seizure disorders
	Asthma	High blood pressure	Manic depression
	Spinal disc disorders	Breast cancer	HIV
	Melanoma	Stroke	Chronic bronchitis
	Infertility	Multiple sclerosis	Substance abuse
	COPD	Joint replacement	Muscular dystrophy
	TIA	Diabetes	Kidney stones
	Other Demyelinating disorders	Ulcerative colitis	Emphysema
	Leukemia	Peripheral vascular disease	Uterine disorders

HOME I ABOUT US I CONTACT US I CAREERS I LINKS I PRODUCTS I SIGN UP I REQUEST A QUOTE I AGENTS I ADMIN

Young�s Insurance Services, Inc.
2950 Felton Rd., Suite 204, East Norriton, PA 19401

Phone: 610-275-7923 Fax: 610-275-7925
Email: office@yisonline.com