Health Insurance Request
Please fill out the questionnaire to see if you qualify for a subsidy that could potentially lower your premium to zero or at a reduced cost.
Personal Information
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Zip Code
*
Household Information
Are You Applying for Yourself Or Household?
Please Select
Self
Household
How many people are in your household (including yourself)?
Do You have dependents under age of 26?
Income Information
What Is Your estimated Income for this year?
Are You currently employed, self-employed or unemployed?
Please Select
employed
Self-Employed
Unemployed
Do you currently have health insurance?
Please Select
Yes
No
If yes, who is your current provider?
Have You lost health insurance coverage in the past 60 days?
Health Coverage Needs
Do You have a specific plan preference (e.g., HMO, PPO, EPO)?
Are You Interested in dental and vision coverage?
Please Select
Yes
No
If you do not qualify in a marketplace subsidy or prefer a private plan. What is your monthly budget for health insurance premiums?
How would you prefer to be contacted?
Please Select
Phone
Text
Email
What is the best time to reach you if you prefer to be contacted by phone?
Feel Free to Leave a Message Here:
Submit
By filling out your information below, you are giving permission for Maria Your Benefitter to contact you with your insurance inquiry.
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