Health Insurance Quote under 65
Application for Health Insurance Quote
Preliminary Insured Information Submission Form. This is not issuance of health insurance. You must review a formal application with a Health Insurance Agent to determine your needs and eligibility. If you would like to recend your consent, please send an email to Heather@benefitsolutionsok.com NOTE: No Fees will ever be collected, unless by a licensed agent upon you authorizing a contract for health insurance services. All fees will be paid directly to the insurance company and will not be paid to the insurance agent. Your information is confidential. Heather Patterson NPN 19374664
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What county do you live in ?
Example, Oklahoma, Payne, Noble
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Prefer not to provide
Tobacco in the last 12 months ?
Please Select
Yes
No
Martial Status
Please Select
Single
Married
Occupation
Employer Name
Does your employer offer health insurance?
Yes
No
If yes, do they pay a portion of the premium for YOU?
Yes
No
How much? (How much or a percentage)
Example: 5% or $300
Do they pay a portion of the premium for your DEPENDENTS?
Yes
No
How much? (How much or a percentage)
Example: 5% or $300
Current Health Plan
Date coverage ends or ended
*
-
Month
-
Day
Year
Date
Which best describes your health care needs?
I/my family only goes to the doctor for well check ups and for the occasional illness. The prescriptions I have are generic. LOW medical expenses
I/my family go to the doctor regularly for a medical condition. The prescriptions we have include brand name drugs. Ex, Vyvanse, Ozempic MEDIUM medical expenses
I expect to have higher medical costs this year. For example a surgery, having a baby, etc. HIGH medical expenses
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Are you or your spouse currently pregnant?
Yes
No
Are considering pregancy in the future
Household income (includes everyone in your house working that is included in your 2025 taxes) This is collected because you might be eligible for a subsidy. A subsidy is a payment toward your premium that the federal governnment pays, thus reducing your monthly payment. If you are self employed you could use last years income as an estimate if you feel like 2025 will be a similar year.
How many household members claimed on your tax return? This will include you and any dependents that you claim on your tax return.
Do you have a tribal CDIB card or have tribal benefits? If yes, please mark those who apply
Me
Spouse
Dependents
What tribe are you a member of ?
These are true for me and my family
*
Lost medical coverage
Had a baby or adopted a child
Move to a different ZIP Code
Got a divorce or had a death in my tax household
Got declined for Sooner care or Medicaid
None of the above
The following is true:
*
I do have documentation proving my loss of coverage.
I do NOT have documentation proving my loss of coverage.
Are you or your spouse self employed?
Please Select
Yes
No
Current physicians you would like to be in network with
List of all prescribed medications, how often and for what reason, include any medical conditions or medical history including heart attack, stroke, cancer, injuries, ongoing treatments or treatment recommendations that are pending.
Please provide the name of the person or source that referred you.
Would you like to cover a dependent
If NO please hit next
Spouse
First Name
Last Name
Spouse Employer Name
Does your spouse's employer offer health insurance?
Yes
No
How much? (How much or a percentage)
Example: 5% or $300
If yes, do they a portion of the premium for THEM? (your spouse)
Yes
No
Do they pay a portion of the premium for their DEPEDANTS?
Yes
No
How much? (How much or a percentage)
Example: 5% or $300
Gender
Please Select
Male
Female
Prefer not to say
Date of Birth
-
Month
-
Day
Year
Date
Current physicians you would like to be in network with
Dependent #1
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Prefer not to say
Dependent #2
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Prefer not to say
Dependent #3
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Prefer not to say
Dependent #4
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Prefer not to say
Current physicians you would like to be in network with
List of all prescribed medications, how often and for what reason, include any medical conditions or medical history including heart attack, stroke, cancer, injuries, ongoing treatments or treatment recommendations that are pending.
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I would also like a quote for any of the following
Dental
Vision
Life
Accident
Living Benefits (Critical Care/Cancer)
Thank you for the opportunity to quote your health insurance !
By hitting submit I agree to allow a licensed agent to review my needs. You will receive a quote via email within 3 business days. If this is BEFORE November 1, 2025 you will NOT receive a quote until the 2025 plans come out. So at the earliest date you will receive your 2025 quote will be November 6, 2025.
Submit
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