Give Yourself a Chance &

Get a FREE Quote Today!

-100% FREE Wellness & Preventive

-Unlimited Lifetime Benefits

-Vision, Dental, & Life Coverage Available

For Self-Employed Individuals, Families and Small Businesses 

Customize the Protection that is Right for You & Your Family.

Full Name

Gender

Age

Smoker

Medical History (Last 5 Years)

High Blood Pressure

High Cholesterol

Surgeries

Heart Conditions

Anxiety/Depression

Pregnant/Maternity

Renal Failure

Cancer

No, I am healthy.

Spouse Full Name (if applicable)

Spouse's Gender

Spouse's Age

Dependents (if applicable)

[List: First Name/Age/Gender]

Postal Code

Email

Phone Number

Best Time to Contact You

9AM - 12PM

12PM - 3PM

3PM - 6PM

6PM - 8PM

Interest in (check all that apply):

Health

Dental/Vision

Supplemental Ancillary

Medicare

Life

Travel

Legal Protection

Pre-Need/Final Expense

Major carriers: Aetna, Humana, Cigna, BlueCross BlueShield, United healthcare, Anthem, 

Mutual of Omaha, Ameritas, Americo Life, Medico, Foresters Financial, 

National Guardian Life, Transamerica, Genworth Life, Gerber Life, National General,

Prudential Financial, Manhattan Life, and American General.

Licensed to serve areas in Arizona, Ohio, & Texas.

  © Matty Hui I Health and Wellness Consultant & Licensed Agent I Phoenix, Arizona