Your Licensed Agent

Alton Taylor

Licensed Insurance Broker

Health Plus One

Client Intake Form

Welcome! Alton Taylor has sent you this form to gather your details so we can find the best coverage for you.

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Your Information

First Name *

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Last Name *

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Date of Birth

Phone *

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Street Address

City

State

ZIP

Authorization & Consent

By completing this intake form, I authorize Health Plus One Agency and its licensed agents to contact me regarding health and life insurance products by phone or email. The information I provide will be used solely to help match me with appropriate coverage options.

I understand that sensitive information (such as Social Security Numbers) is not collected on this form and will only be requested at the time of a formal application through the carrier's secure enrollment system.

Text-message (SMS) follow-up is optional — you will be asked on the final step whether you consent to receive SMS. This is a solicitation for insurance. You may opt out of future communications at any time by replying STOP to any text message or contacting us at 813-445-3307. See our SMS Consent Policy. SMS Consent Policy.

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