Palffy Insurance Group

Insurance "Gap" Coverage Quote Request

"Gap" Coverage Quote Form
*Required Fields

First Name*

Last Name*

Phone Number*

Email Address*

Zip Code*

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")

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.

"Gap" Coverage

There are many different types of Insurance "Gap" Coverage. We'll show you all the options available to you and help you pick the plan (or plans) that fit your situation.

These plans complement your health insurance by providing benefits beyond what your health coverage provides. They are not a subsitute for health insurance. Instead, they fill in the gaps of your coverage and help pay for deductibles and other out-of-pocket expenses.

Usually, the benefits are paid directly to you so that you can decide how to use the money. You can use it to pay medical bills. If you're off work for an extended period of time, you could use the cash to help pay your living expenses.

If you'll have problems paying the deductible or maximum out-of-pocket on your health coverage, this type of insurance can put you in a better financial situation if you ever need to use your health plan.

If the only health insurance plan that you can afford has high deductibles, high out-of-pocket maximums, and various out-of-pocket expenses, then you probably can't afford to go without Insurance "Gap" Coverage.