Supplemental Benefits Quote Request Please take a moment to fill out the form below and one of our local insurance agents will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only. General InformationContact Person:* First Last Contact Phone Number:*Contact Email Address:* Preferred Method of Contact:*PhoneEmailBest Time to Call:*MorningAfternoonEveningWho are you currently insured with?Have you ever carried a Supplemental Benefits policy?YesNoIf so, has the policy been non-renewed or cancelled in the last 5 years?YesNoThe prospect has expressed interest in the following products: Accident Cancer Dental Short Term Disability Group Term Life Specified Critical Illness Medical Bridge Vision Comments or Remarks:I consent to be contacted by a representative of IHT to receive a Supplemental Benefits Quote.* I Agree CommentsThis field is for validation purposes and should be left unchanged. Request Quote This iframe contains the logic required to handle Ajax powered Gravity Forms.