Contact

Get an Individual
Insurance Quote

To get an individual insurance quote from AHS, please fill in the questionnaire below. The information you provide below will help us provide an estimate of premium for the insurance products you request. Rates quoted are not final and cannot be determined until complete applications are submitted for underwriting consideration and approval.

  

Schedule an Insurance
Consultation

To schedule a time to speak with Jim Houghton or Lorie Graves, you can always reach Affordable Health Solutions in downtown Portsmouth, NH.

Affordable Health Solutions
155 Fleet St.
Portsmouth, NH 03801
603.433.8821

Contact Info

* Required Information
* Your Name
* Street Address
* City
* State
* Zip Code
* Phone
Fax
* Email

Best way to contact you to discuss your quote:
Phone    Fax    Email

Insurance Products

Type of Insurance: (Check all that apply)
Individual (non group) Health    Short Term Medical   

Term Life Insurance

Death Benefit
$100,000   $250,000   $500,000   $1,000,000   Other

Policy Term
10 years    15 years    20 years    30 years    Other

Who Is Being Insured?

Primary Insured
Last Name

First Name

Gender Male Female
D.O.B.
Height
Weight
Tobacco Use Yes No
Spouse
Last Name

First Name

Gender Male Female
D.O.B.
Height
Weight
Tobacco Use Yes No
Dependent 1
Last Name

First Name

Gender Male Female
D.O.B.
Height
Weight
Tobacco Use Yes No
Dependent 2
Last Name

First Name

Gender Male Female
D.O.B.
Height
Weight
Tobacco Use Yes No
Dependent 3
Last Name

First Name

Gender Male Female
D.O.B.
Height
Weight
Tobacco Use Yes No
Dependent 4
Last Name

First Name

Gender Male Female
D.O.B.
Height
Weight
Tobacco Use Yes No

 

Additional Optional Information

In the last five years have any of the proposed insured been diagnosed, treated or medicated for any specific medical condition or injury? Yes No

If yes, please provide the following:

Proposed Insured's Name

Condition / Injury

Treatment / Medication

Onset Date: Mo / Yr

Last Treatment Date: Mo / Yr

Is the condition still present?
Yes No

Proposed Insured's Name

Condition / Injury

Treatment / Medication

Onset Date: Mo / Yr

Last Treatment Date: Mo / Yr

Is the condition still present?
Yes No

Proposed Insured's Name

Condition / Injury

Treatment / Medication

Onset Date: Mo / Yr

Last Treatment Date: Mo / Yr

Is the condition still present?
Yes No

Proposed Insured's Name

Condition / Injury

Treatment / Medication

Onset Date: Mo / Yr

Last Treatment Date: Mo / Yr

Is the condition still present?
Yes No

Proposed Insured's Name

Condition / Injury

Treatment / Medication

Onset Date: Mo / Yr

Last Treatment Date: Mo / Yr

Is the condition still present?
Yes No

Proposed Insured's Name

Condition / Injury

Treatment / Medication

Onset Date: Mo / Yr

Last Treatment Date: Mo / Yr

Is the condition still present?
Yes No

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