Submit form for quote on a supplemental policy from AFLAC
Personal Information
Name:
Age:Birthdate:
Age:Birthdate:Address:City:State: Zip:
City:State: Zip:Phone:E-mail:
E-mail:Type of Coverage (select all that apply)
Type of Policy
Medical History
Does anyone to be covered use tabacco?
Has anyone to be covered been treated in an emergency room in the last 12 months?
Has anyone to be covered been diagnosed or treated for cancer in the last 5 years?
Please call ahead for an appointment - (502) 233 - 8043
Call us! (502) 233-8043
