Get a Quote for Insurance

Affincon is here to help your with all your insurance needs. Please complete the form below and an agent will contact you shortly to consult with your about the best health insurance options for your needs.

 
Individual Health Insurance Quote Form

Fields marked by an asterisk (*) are required fields.

 

Requested Coverage Information


Health Coverage Requested:       Effective Date Requested: 
 

Current Coverage Information


Current Coverage: 
Current Carrier: 
 

Insured Information


Name*     Gender  
Date of Birth*
Address   Unit/Apt/Lot #  
City   State     Zip  
County
Email*
Home Phone   Work    Cell 
Preferred Contact Method*     Best Time to Call:* 
 
Height*  Feet     Inches
Weight*  lbs
Smoker*
 

Family Information


 Name  DOB  Sex  Height  Weight
 

Required Medical Information


Please describe any medical conditions and to who they apply:
List any Medications
being taken and by whom:

The protection of your privacy is important to us. Rest assured that the personal information you provide us with will not be disclosed to other parties and will be used solely for the purpose of bringing you the best service possible.
Hear what our customer have to say

"Ron Dutton has done an outstanding job of handling my firm's health insurance coverage. We have been using him since shortly after we started the company, and he was able to find plans that were ideally suited to our needs. Recently, he was able to review our coverage and recommend some changes that would save us money while keeping the same level of coverage. I recommend him without reservation."
John D. Hadden
Attorney at Law
Atlanta, GA