Gulf Breeze Insurance Inc.

Real People with Real Solutions

Information for Quoting purposes only. You are not obligated in any way. Gulf Breeze Insurance, Inc. is licensed in the states of Florida & Alabama. FL#L003722 / AL#A272605 privacy policy

This form tells us what you desire in coverage, so please complete. We appreciate your business.

Please check all mail folders for you custom quotes. Add gulfbreezeinsurance.com to you allowed mail list.

Current Coverage Type, if any:

Currently Covered?

If So, Who is Covered?

If So, Coverage Type?

Customize Your Quote

Who is to be Covered?

Desired Effective Date?

Your Gender?

Spouse Gender?

Your Birth date?

Spouse Birth date?

Tobacco Products?

Height? Ft Inches

Weight

Child's Gender

Child's DOB?

Child's Gender

Child's DOB?

Child's Gender

Child's DOB?

Please List Gender & DOB for Additional Children

Customize the Coverage and Explanations for Cost Adjustments

Coverage Type? PPO vs HSA

PPO: Traditional Plans: Office Visits, deductibles etc.

HSA: Health Savings Account. High deductible health plans coupled with savings accounts for out of pocket medical expenses up to and including dental, vision, etc.

Customize your Plan of Choice
Office Visit / Deductible Combinations:
Choose the plan that best describes you.

Do You prefer

.... benefits like those provided by employers and prefer to minimize the risk and have seen a doctor in the last year:

Rx Deductible?

or balance / HSA Plans

... want a balance between cost and coverage; want to be involved with medical decisions and responsibilities of family and retirement savings are priorities: includes HSA plans

Rx Deductible?

Do you want a plan just in case of catastrophic condition: 100% after deductible

Rx deductible is $1000.

Office visit co pays effect the amount you pay each month. Those that do not go to the doctor all the time may not need unlimited visits and could essentially reduce premium by selecting amount of visits per year.

Deductible: the deductible effects the amount you pay each month significantly. The higher the deductible the less you pay per month. You do not have to meet the deductible before regular office visit co-pays. 90% of our clients choose $2500 option.

Rx Deductible: effect the amount you pay each month. The deductible is the amount you pay before co-pays start. By adding a deductible the premium is reduced. This option is totally up to you.

Dental Option:

Life Insurance Option?

Best Time to contact? am/pm

First Name

Last Name

Zip Code

Phone w/Area code in case email gets returned.

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Gulf Breeze Insurance Inc.
Licensed in Florida L003722
Alabama A272605
850-934-7992