Worthington Insurance

34 East Afton Ave.
Yardley, PA 19067
Ph: 215-493-4170
Fax: 215-493-8833

Good health is something we all take for granted. But with the rising cost of health care and the ever-present threat of an accident or illness, health insurance is a must. It’s a well known fact that preventive health care is the best means to a long and healthy life. Did you know that health insurance can provide coverage to lower the cost of preventive health care? It also covers the cost of preventative maintenance. But most importantly, its primary purpose is to provide coverage in the event of a major or catastrophic illness. All coverage is subject to deductibles and limitations. This coverage can be purchased on an individual or on a group basis. The plan you choose will be customized to fit your specific needs.

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*	How did you hear about us?
*	First Name
*	Last Name
	Middle Initial
	Suffix
*	Email
*	Phone	(nnn-nnn-nnnn)
	Phone Extension
*	Phone Type
	Company Name
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	Submit incomplete form Check this box if you wish for us to contact you instead of filling out the rest of this form. See below note for more info.

Please note: You may, if you wish, forgo filling out the remainder of this form. If you wish to do so, simply ensure that the "Submit Incomplete Form" checkbox above is checked and scroll to the bottom of the page and press the "Submit" button. We will contact you via the method you indicated above to obtain the necessary information. Otherwise, complete the form, and we'll provide your quote via the method you indicated above.

*	County
*	Mobile Phone	(nnn-nnn-nnnn)
*	Type of Business
*	Description of Business Operations
*	Number of Locations
*	Number of Employees
	Do you currently have Group Health Insurance?
	If yes, when does your current policy expire?
	If yes, who are you currently insured with?
*	Which type of Plan?
*	Optional Coverage select what you would like:
	Group Dental Insurance
	Group Disability Insurance
	Group Life Insurance
	Group Long Term Care
	401K & Retirement Plans
	Any Comments/ Questions?
	This information has been reviewed and the customer agreed upon. In connection with the application for insurance, we may review your credit report or use a credit based insurance score based on the information contained in that report. We may use a third party in connection with the development of your insurance score.


	Copyright © 2006. C A Worthington Insurance, Inc.