Health Insurance Quote Request:

Please complete this short questionnaire in full for your FREE no obligation quotes.  These quotes will be from the plans and insurance carrier(s)
found to be best suited to your stated needs and budget. You may be contacted if further information is needed to prequalify you for the best, most cost effective quotes.

* = Required Information

Quotes desired on the following:

Full Coverage PPO Health Savings Account Dental

High Deductible Health Plan Short-term Medical
 
I can afford no more than $ per month for health insurance
Other needs & specifications

Contact Information:

First Name*
Last Name*
Address*
City*
State*
Zip*
Primary Phone*
Alternate Phone
Email*
Best time to contact*
Preferred method
of contact
Phone Fax Email Mail

Applicant Information:

Gender
 Male Female
Age
Height
Weight
Tobacco User
(last 12 months)
Yes No
Self Employed
Yes No
Type of business
Currently insured
Yes No
If yes, name of insurer
Current Premium
Date new
coverage desired
Maternity coverage desired
Yes No
Preexisting health issues for anyone to be covered
Yes No
If yes, please explain

Families Information

Spouse's First Name
Spouse's Last Name
Age
Height
Weight
Tobacco user
(within last 12 months)
Yes No
Age of each child
to be covered
 

Direct Contact Information

Mailing Address

ABS LLC
P.O. Box 16234
Hooksett, NH 03106

Phone Numbers

Nashua, NH:
603-598-2596

Hooksett, NH
603-622-5700

Toll Free:
1-877-842-1546

Fax Number

603-218-6447

Email

Email Affordable Benefit Solutions