Information received from this request form will be sent to Wayne Horne Insurance Agency for our use only and will not be sold, given to or distributed to any other parties. A quote will be based on Illinois Medicare Supplement, Life, Short Term Care Coverage, Long Term Care Coverage, Recovery Care Coverage, Cancer Care Coverage, or Final Expense insurance policy information provided and does not guarantee acceptance of the risk by us. The precise coverage afforded is subject to meeting underwriting guidelines, and the terms, conditions and exclusions of the policy as issued. By submitting this request you acknowledge that this is neither an offer to insure nor a guarantee of insurance. Completion of this form does not entitle you to an Illinois Medicare Supplement, Life, Short Term Care Coverage, Long Term Care Coverage, Recovery Care Coverage, Cancer Care Coverage, or Final Expense insurance policy. We are licensed in Illinois and will not provide group health insurance quotes for other states.