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"The Largest Insurer in North Carolina with 3.6 million insured."

	Experienced insurance agents who can assist you with making the right choice for yourself and your family.
	Plans with convenient copayments for doctor visits, emergency room services, urgent care, physicals, and more.
	Blue Advantage offers the largest network of doctors and hospitals in North Carolina.
	You are covered throughout the United States and in more than 200 countries and territories worldwide.

Rate Quote

* 1. Applicant information

* Applicant's First Name:

* Applicant's Last Name:

*Applicant's Contact Phone Number:

* Applicant's Date of Birth:

mm/dd/yyyy

* Applicant's E-mail Address:

* County of Residence:

* Zip Code:

* Applicant's Gender:

Male Female

*Tobacco Usage during past 12 months:

Yes No

* Height and Weight:

Height: Weight:

2. Spouse information

Include spouse on policy

Spouse's First Name:

Spouse's Last Name:

Spouse's Date of Birth:

mm/dd/yyyy

* Spouse Gender:

Male Female

Tobacco Usage during past 12 months:

Yes No

* Height and Weight:

Height: Weight:

3. Dependent information

Dependant 1
Gender: Male Female
Date of Birth: mm/dd/yyyy

4. Insurance Information

* Coverage needed for how long:

* Current Insurance:

What best describes your current needs? (You may select more than one)

	My employer no longer offers coverage.		I am comparing rates.
	I have cobra		I am starting a new business.
	I need health insurance immediately.		My insurance has been cancelled.

5. Include dental quote?

6. Include maternity quote?

Yes No

7. Plans to quote?

Blue Advantage®	Blue Options HSA (sm)	Group Plans
Medicare	Short Term Care	Long Term Care

* 8. Quote delivery method

* 9. Who do you want to contact?

By Phone By E-mail

Ronald Diane

BlueChip Insurance Agency is an independent authorized producer/agency licensed to promote products from Blue Cross and Blue Shield of North Carolina (BCBSNC). The content contained in this site is maintained by BlueChip Insurance Agency. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered mark of the Blue Cross and Blue Shield Association

BlueChip Insurance Agency - Blue Cross and Blue Shield Authorized Group Health and Life Insurance Agent in Wilmington, North Carolina (NC).