Pinnacle Group Insurance
	To check rates on our individual products, please answer the following questions. All plans are rated based on age, and some plan choices/rates are based on county of residence, disability, current insurance, etc. Please complete the questions below so that we can direct you to the correct products and their rates. Thank you for filling out the form below. Are you a resident of Tennessee? Yes No Date of Birth: Gender: [Select One]MaleFemale County: [Select One]United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaidjanBahamasBahrainBangladesBarbadosBelarusBelgiumBelizeBeninBermudaBoliviaBosnia-HerzegovinaBotswanaBouvet IslandBrazilBritish Indian O. Terr.Brunei DarussalamBulgariaBurkina FasoBurundiButhanCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African Rep.ChadChileChinaChristmas IslandCocos (Keeling) Isl.ColombiaComorosCongoCook IslandsCosta RicaCroatiaCyprusCzech RepublicCzechoslovakiaDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEstoniaEthiopiaFalkland Isl.(Malvinas)Faroe IslandsFijiFinlandFranceFrance (European Ter.)French Southern Terr.GabonGambiaGeorgiaGermanyGhanaGibraltarGreat Britain (UK)GreeceGreenlandGrenadaGuadeloupe (Fr.)Guam (US)GuatemalaGuineaGuinea BissauGuyanaGuyana (Fr.)HaitiHeard & McDonald Isl.HondurasHong KongHungaryIcelandIndiaIndonesiaIraqIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazachstanKenyaKirgistanKiribatiKorea (North)Korea (South)KuwaitLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartinique (Fr.)MauritaniaMauritiusMexicoMicronesiaMoldaviaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherland Antilles NetherlandsNeutral ZoneNew Caledonia (Fr.)New ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana Isl.NorwayOmanPakistanPalauPanamaPapua NewParaguayPeruPhilippinesPitcairnPolandPolynesia (Fr.)PortugalPuerto Rico (US)QatarReunion (Fr.)RomaniaRussian FederationRwandaSaint LuciaSamoaSan MarinoSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovak RepublicSloveniaSolomon IslandsSomaliaSouth AfricaSoviet UnionSpainSri LankaSt. HelenaSt. Pierre & MiquelonSt. Tome and PrincipeSt.Kitts Nevis AnguillaSt.Vincent & GrenadinesSudanSurinameSvalbard & Jan Mayen IsSwazilandSwedenSwitzerlandTadjikistanTaiwanTanzaniaThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluUS Minor outlying Isl.UgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis & Futuna IslandsWestern SaharaYemenYugoslaviaZaireZambiaZimbabweOther Smoker: [Select One]YesNo Do you want Maternity Coverage? [Select One]YesNo Are you interested in Dental Coverage? [Select One]YesNo Thank you for allowing the Pinnacle Group the opportunity to provide you a proposal and service your Insurance needs.