Health Quote Form

1
Select Your Agent
Please Select
Please Select
GABBY
CECY
ANA CARINA
ASHLEY
MARANDA
CANDY
SAMUEL
ROSEMARIE
MARTHA
2
Name* This field is required.
First Name
Last Name
3
Phone Number* This field is required.
Example: xxx-xxx-xxxx
4
Email Address
example@example.com
5
Zipcode
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
CountyPlease enter COUNTY
Street Address
Street Address Line 2
County
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Age
8
Monthly Income
This is the amount you see on your paycheck before taxes and deductions. Another way to calculate: Hourly rate x hours worked= gross pay
9
What is your marital/tax filing status?
Single (file alone, no spouse)
Married filing jointly (file with spouse)
Head of household (file alone with minimum of 1 dependent)
10
Need coverage for any of the following? (Please select all that apply)Health Insurance: Covers medical services like doctor visits, hospital stays, and prescription drugs." Vision Insurance: Covers eye exams, glasses, and contact lenses. Dental Insurance: Covers preventive care, fillings, and other dental treatments.
Health
Vision
Dental
NONE
11
Do you claim any dependents?
Please Select
Please Select
0
1
2
3
4
5
6
12
Spouse Age
13
Is your spouse employed?
Yes
No
Other
14
Spouse Monthly Income
This is the amount they see on your paycheck before taxes and deductions. Another way to calculate: Hourly rate x hours worked= gross pay
15
Need coverage for any of the following? (Please select all that apply)Health Insurance: Covers medical services like doctor visits, hospital stays, and prescription drugs." Vision Insurance: Covers eye exams, glasses, and contact lenses. Dental Insurance: Covers preventive care, fillings, and other dental treatments.
Health
Vision
Dental
NONE
16
Dependent #1 Age
Age
17
Need coverage for any of the following? (Please select all that apply)Health Insurance: Covers medical services like doctor visits, hospital stays, and prescription drugs." Vision Insurance: Covers eye exams, glasses, and contact lenses. Dental Insurance: Covers preventive care, fillings, and other dental treatments.
Health
Vision
Dental
NONE
18
Dependent #2 Age
19
Need coverage for any of the following? (Please select all that apply)Health Insurance: Covers medical services like doctor visits, hospital stays, and prescription drugs." Vision Insurance: Covers eye exams, glasses, and contact lenses. Dental Insurance: Covers preventive care, fillings, and other dental treatments.
Health
Vision
Dental
NONE
20
Dependent #3 Age
Age
21
Need coverage for any of the following? (Please select all that apply)Health Insurance: Covers medical services like doctor visits, hospital stays, and prescription drugs." Vision Insurance: Covers eye exams, glasses, and contact lenses. Dental Insurance: Covers preventive care, fillings, and other dental treatments.
Health
Vision
Dental
NONE
22
Dependent #4 Age
Age
23
Need coverage for any of the following? (Please select all that apply)Health Insurance: Covers medical services like doctor visits, hospital stays, and prescription drugs." Vision Insurance: Covers eye exams, glasses, and contact lenses. Dental Insurance: Covers preventive care, fillings, and other dental treatments.
Health
Vision
Dental
NONE
24
Dependent #5 Age
Age
25
Need coverage for any of the following? (Please select all that apply)Health Insurance: Covers medical services like doctor visits, hospital stays, and prescription drugs." Vision Insurance: Covers eye exams, glasses, and contact lenses. Dental Insurance: Covers preventive care, fillings, and other dental treatments.
Health
Vision
Dental
NONE
26
Dependent #6 Age
Age
27
Need coverage for any of the following? (Please select all that apply)Health Insurance: Covers medical services like doctor visits, hospital stays, and prescription drugs." Vision Insurance: Covers eye exams, glasses, and contact lenses. Dental Insurance: Covers preventive care, fillings, and other dental treatments.
Health
Vision
Dental
NONE
28
Monthly Budget
Less than $100
$100-$200
$200-$300
$300-$400
$400-$500
$500-$700
$700-$900
$900-$1000
Over $1000
Other
29
Is there any additional information you'd like us to consider?
For example, medical conditions, medications, specific doctors, networks, specialists, or additional notes you'd prefer to keep in mind when selecting your health plan.
30
If unsure about any of the questions regarding what is filed on your taxes, please upload a copy of your most recent IRS Form 1040. We are also tax professionals that have insight on how best to quote you based on IRS and Marketplace standards.This helps determine eligibility for financial help and accurate health insurance quotes. ALL information will be handled securely and used solely for quoting purposes.
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**THIS IS NOT REQUIRED!!** (You can usually find this form in the first couple of pages of your income tax return package.)
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