MarketPlace 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. All Questions with *are required to obtain your eligibility.
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
Address
*
Do you currently have health insurance?
*
Please Select
Yes
No
If no current insurance, did you lose health coverage in the past 60 days?
Household Information
Are You Applying for Yourself Or Household?
*
Please Select
Self
Household
How many people are in your household (including yourself)?
If there are dependents, what are the ages?
If multiple enter with a comma (5, 6, 7,)
Income Information
What Is Your estimated Income for this year?
*
Are You currently employed, self-employed or unemployed?
Please Select
employed
Self-Employed
Unemployed
If yes, name of employer?
Health Coverage Needs
If you do not qualify for a marketplace subsidy and or prefer a private plan. What is your monthly budget for health insurance premiums?
Do You have a specific plan preference (e.g., HMO, PPO, EPO)?
Are You Interested in supplemental coverages like dental and vision coverage?
Please Select
Yes
No
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 of Your Benefitter Advising to contact you with your insurance inquiry. Your information will be kept confidential and private.
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