Fortner Insurance is the expert when it comes to meeting your insurance needs throughout Peoria, Washington, Morton, East Peoria, Peoria Heights, Dunlap, Bloomington and all across Central Illinois! Whether you are in need of personal insurance products like auto insurance, health insurance, car insurance, life insurance, home insurance, motorcycle insurance, watercraft insurance, or you need commercial insurance, workers compensation assistance or even an umbrella policy, Fortner insurance is your total solution!

Xapsis Integrated Marketing

General Information

Date Taken: Aug 16, 2017

Spouse and Dependants

Name DOB Age HT WT
+Add Dependant

Current Health Plan:

Plan Design


Anyone on the policy have any current health challenges? If yes, please list:

Applicant's Name Conditions Date of Treatment Medications Limitations
+ Add Row