Health Insurance Quote Request

Health Insurance Quote Request

Navigating insurance options can be overwhelming. Working with a licensed insurance professional can make the process as simple as 1-2-3.
1. Fill out the form below to request an insurance quote so we can help you find the best plan for your needs and budget.
2. Schedule an appointment to discuss your needs sand budget. This ensures we find the most suitable plan for you.
3. We will review your personalized insurance quote and help you understand your coverage and plan options.
After you have reviewed your personalized quote, you can get enrolled in the coverage of your choice with the assistance of a Licensed Insurance Agent for peace of mind and financial security.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth (DOB)

MonthDayYear
Date
Gender
Tobacco (4 or more times weekly in the past 6 months.)
Zip code
Residing State
Residence County
2. Spouse

If applicable, enter spouse information below.
Spouse name

First NameLast Name
Date of Birth (DOB)

MonthDayYear
Date
Gender
Tobacco (4 or more times weekly in the past 6 months.)
3. Dependent information

Enter dependent information below whether they need coverage or not.
Dependent #1
Date of Birth (DOB)

MonthDayYear
Date
Gender
Tobacco (4 or more times weekly in the past 6 months.)
Is the dependent applying for coverage?
Dependent #2
Date of Birth (DOB)

MonthDayYear
Date
Gender
Tobacco (4 or more times weekly in the past 6 months.)
Is the dependent applying for coverage?
Dependent #3
Date of Birth (DOB)

MonthDayYear
Date
Gender
Tobacco (4 or more times weekly in the past 6 months.)
Is the dependent applying for coverage?
Dependent #4
Date of Birth (DOB)

MonthDayYear
Date
Gender
Tobacco (4 or more times weekly in the past 6 months.)
Is the dependent applying for coverage?
Add any additional dependent information below; DOB, Gender, Tobacco use.
Are there any doctors/medications you would like to make sure is covered?
Is anyone applying for coverage Pregnant?
The new law provides free services related to pregnancy and you may even qualify for more assistance based on your income.
4. Household Information

This is needed to check and see if you qualify for a tax credit to lower the cost of your insurance, and if so what amount.
Number of Household Members
How many members in your household total that is included on your tax return? Example: 2 adults and 3 dependents is 5 household members.
What is the expected household income for the year.
This would include the taxable income of the you, a spouse, and any dependents, including those who don't need coverage.
Parent of child under 19 that lives in your household (Even if you don't claim them on taxes.
Is anyone applying for coverage currently eligible for other coverage elsewhere? (Check all that apply)
Qualifying Events for Special Enrollment Periods

A change in your situation like getting married, having a baby, or losing health coverage can make you eligible for a Special Enrollment Period, allowing you to enroll in health insurance outside the yearly Open Enrollment Period. Will any of the following occur within the next 60 days, or did any of the following happen within the past 60 days? (If so, check all that apply)
Lose of Health Coverage
Changes in Household
Changes in Residence
Other qualifying life events events
I would also like information on the following: (check any that apply)
I agree to receive contact via phone call, email, and/or text messages regarding my health plan options. (Your carrier's message and data rates may apply)
I understand that my information is kept private and not shared with third parties, and that I will only be contacted by Dawn Thomas Insurance Agent about my quote.
5. Book Appointment

Schedule an appointment to discuss your insurance needs and budget. This allows us to find the most suitable plan for you.
To finish submitting your quote request you MUST click the green button below that says ALL DONE
Should be Empty:

Health Insurance Quote Request

2. Spouse

3. Dependent information

Dependent #1

Dependent #2

Dependent #3

Dependent #4

4. Household Information

Qualifying Events for Special Enrollment Periods

5. Book Appointment