Website Quote Questions with email

1

Referrer

2

I need healthcare for* This field is required.

Myself

Parent+Child or Spouses

Family

Small Business

3

Do you live in the state of Washington?* This field is required.

YESNO

4

Do you have a Health Savings Account or want to use one?* This field is required.HSA allows you to put money away and withdraw it tax free, as long as you use it for qualified medical expenses, like deductibles, copayments, coinsurance, and more. Yes, it rolls over!

YESNO

5

Are you 1099 status or have an EIN* This field is required.

YESNO

6

How many times do you see providers or specialists?* This field is required.

I never go

1 or 2 times a year

More than 3 times a year

7

How many times do you go to the emergency room or urgent care?* This field is required.

I never go

More than 3 times in a year

1 or 2 times a year

8

How many people in your group?* This field is required.Less than 3 people would only be eligible for our individual lans we have several options to review.

3

5 or more

9

Good news! indipop has a healthcare plan and offers $0 for unlimited primary care, annual wellness and more! Enter your info to see the rate* This field is required.

example@example.com

10

Good news! indipop has a healthcare plan and offers unlimited primary care and $50 co-pays to see specialists! Enter your info to see the rate* This field is required.

example@example.com

11

Good news! You are eligible to enroll in the HSA compatible plan. You can also view our most popular indipop plan to compare. Enter your info to see the rate.* This field is required.

example@example.com

12

Unfortunately, you need to be have 1099 status or have an EIN to utilize the Essential + HSA plan. But the good news is we have a plan to compare it to without the HSA. Enter you info to see the rate.* This field is required.

example@example.com

13

Good news! We have two group plans for teams 3 or more. Fill out your info to review the options.* This field is required.

example@example.com

14

We have one group plan that is for a team of 3. Fill in your info to review the rates and information.* This field is required.

example@example.com

15

Phone Number* This field is required.

Please enter a valid phone number.

16

1 more step to see the plan* This field is required.

First Name

Last Name

17

Lead SourceThis hidden input sets the Lead Source on HubSpot

18

Deal NameThis hidden input sets the Deal Name on HubSpot based on "First Name" + "Last Name" of the contact.

19

Contact EmailThis hidden input helps HubSpot identify the contact by the email address.