Contact Us

HEALTHMASTERS INC.

The insurance exam people

 

 

 

 

 

 

Online Order Form

 

Applicant Information

* indicates required

First Name*:



MI:



Last Name*:



Date of Birth*:

/  / 


SSN#*:

-  - 


Home Address


Address*:


Apt.


Address:



City, State, Zip*:


   


Phone*:


   


Cell phone:



Business Address:


Company Name:



Address:



City, State, Zip:


   


Phone:


      ext.


Notes:


 

Requirements

Insurance Company Name*:

Case/Policy Number:

Insurance Amount*:

Type of Coverage*:

Life Disability Health LTC Other

Medical Requirements:


Paramedical Exam
Physician Exam
Blood and Urine
Fingerstick
Physical Measurements on Lab Slip


EKG

TVC
Saliva
Stress EKG
X-Ray


Urine
HIV Urine
Other

 

Agent Information

 

Agent Name*:

Agent Contact Name:

Agency Name:

Agency Address*:

City, State, Zip*:

   

Agent Code #:

Agency Code #:

Agent Phone*:

      ext.

Agent Fax:

Home Office-MA, NY City, Long Island, NY*:

Email*:


If you have questions or concerns regarding this order please call 800-444-8384
New York City Only: 212-736-6577

Long Island, NY Only: 516-764-2205