Palffy Insurance Group

Cancer & Critical Illness Coverage Quote Request

Cancer & Critical Illness Insurance Quote Form
*Required Fields

First Name*

Last Name*

Phone Number*

Email Address*

Zip Code*

Which type of policy should we quote for you?

Are you eligible for Medicare?*

Do you have health insurance?*

Date of Birth*


Tobacco Use*



Do you have a family physician?*

When was your last check-up?

List any medical conditions for which you are currently being treated* (if you don't have any, type "none")

List any medical conditions that you recovered from in the last five years* (if you haven't had any, type "none")

List all medications you are currently taking and daily dosages* (if you don't take any, type "none")

Have you ever had any form of cancer?*

Additional Comments:

A sales agent may call you as a result of submitting this form. We may need to clarify some information while completing your quote request. We may call you to discuss your options after you receive your quote.

The information you provide will only be used to satisfy your quote request. Certain information will be shared with insurance companies for quoting purposes only. No insurance company and no other insurance agency will market to you as a result of submitting this form. We do not share your information with outside organizations for marketing purposes.

Cancer & Critical Illness Insurance

Cancer and Critical Illness policies provide a lump-sum payment after you’re diagnosed with a covered illness. Depending on the plan you choose, many illnesses and conditions may be covered including cancer, stroke, heart attack, blindness, disability, organ transplants, and a variety of lesser known diseases. Some policies cover over 100 different diseases.

Cancer and Critical Illness policies complement your health insurance by providing benefits beyond what your health coverage provides.

If you or a loved one is seriously ill, there’s a good chance that you’ll miss a lot of time at work. Even though your health insurance is taking care of the medical bills, you may have a hard time coming up with the rent, mortgage, grocery, and other normal living expenses. You may also incur a number of other expenses like travel to distant hospitals, hotel stays, and covering expenses that health insurance doesn’t cover. These policies are designed to give you the cash needed to make it through these tough times.

In addition, many health insurance plans have very high deductibles. Cancer and Critical Illness policies can eliminate this financial burden.

There’s no doubt that when serious illness strikes, there will be a severe financial burden placed on you and your family. It doesn’t help matters when a seriously ill person worries about finances at the same time they’re trying to focus on getting healthy. These policies are designed to alleviate your financial worries so that you can focus on getting well.