• Let's get started!

    To find the right health coverage for you, we need a few details.

  • By submitting this form, you agree that a licensed insurance agent from CYA Insurance Agency may contact you by phone, text, or email to discuss your health coverage options. You can opt out at any time.

    CYA Insurance Agency is a licensed, independent insurance agency. We are not affiliated with the government or Medicare.

    Your information is kept secure and will never be shared without your consent.

    Once your form is submitted, you'll be prompted to schedule a convenient appointment time with one of our agents.

  • Primary Contact

    Just the basics to get your quote started.
  • Format: (000) 000-0000.
  • Are you applying for coverage yourself?*
  • Have you used nicotine 4 or more times a week in the past 6 months?*
  • Do you have any ongoing health conditions? (e.g., diabetes, heart disease, cancer, high blood pressure)

  • Home Address

    Use the address on your federal tax return.
  • Is your mailing address the same as your home address?*

  • Household Members

    Your marital and tax filing status.
  • Are you married?

  • Select Yes if you're legally married, separated but not divorced, or in a recognized common-law marriage.

    Select No if you're widowed, divorced, or experienced domestic abuse or spousal abandonment.

  • Will you file a joint tax return?*
  • Is your spouse applying for coverage?*
  • Has your spouse used nicotine 4 or more times a week in the past 6 months?*
  • Does your spouse have any ongoing health conditions? (e.g., diabetes, heart disease, cancer, high blood pressure)*

  • Spouse Information

    Needed even if your spouse isn't applying.

  • Children Information

    Add each child who needs coverage.
  • Do you have any children in your household?*

  • Household Income

    Helps us find every tax credit and savings you qualify for.
  • Will you file a federal tax return for 2027?*

  • A few things to know:
    • Use your expected income for the year you'll have coverage.
    • Include income for everyone on your tax return.
    • If you're married, include your spouse's income even if they aren't applying.
    • Not sure what to count? The IRS AGI guide can help, or we'll walk through it with you.

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  • Additional Coverage Questions

    A few quick questions about recent Medicaid coverage.
  • Has anyone applying been denied Medicaid in the past 90 days?*

  • Include someone if the state denied their Medicaid because:

    • Their income is too high
    • The state doesn't cover their household type
    • A child has a waiting period before coverage starts
    • A change in state rules made them no longer eligible

    Don't include someone if they:

    • Never applied, or are still waiting on a decision
    • Were only screened by the Marketplace, not the state
    • Were denied for missing paperwork
    • Have had an income or household change since the denial
  • Is anyone applying losing Medicaid coverage?*

  • Existing Coverage Information

    Tell us about any coverage you have now or could get through work.
  • Is anyone in your household offered health insurance through their own job?*

  • Include someone if:

    • Their job offers health insurance, even if they haven't enrolled or think it costs too much
    • Their employer's enrollment period isn't open right now

    Don't include someone if:

    • They don't work enough hours to qualify
    • The offer is through a spouse's or parent's job
    • Their only option is an HRA, COBRA, or retiree coverage
  • Does anyone applying have health insurance right now?*

  • Life Changes

    These can let you enroll outside open enrollment.
  • Has anyone applying had any of these in the last 60 days?*
  • Will anyone lose health coverage in the next 60 days?*

  • Your Care Preferences

    Helps us find plans that cover the doctors, hospitals, and prescriptions you use.
  • Would you like dental coverage on your quote?*
  • Would you like vision coverage on your quote?*
  • Which hospitals would you like in-network? Pick all that apply.*

  • Almost Done

    A few last questions so we can tailor your options.
  • If an illness or injury stopped your income, how long could you cover your bills?*
  • Do you currently have life insurance?*
  • What monthly budget would you like to stay within?*
  • Should be Empty: