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Fiji
Finland
France
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Philippines
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Portugal
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Russia
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South Sudan
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Age
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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.
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Dental
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Are you self-employed or an employee (W-2)?
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What is your estimated monthly income after business expenses?
Include all money you receive from work minus expenses.
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What is your monthly paycheck before taxes?
This is the amount you see on your paycheck before taxes and deductions. Another way to calculate: Hourly rate x hours worked= gross pay
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What is your marital/tax filing status?
Single (file alone, no spouse)
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Head of household (file alone with minimum of 1 dependent)
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Do you claim any dependents?
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2
3
4
5
6
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6
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Spouse Age
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Is your spouse employed?
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Are they self-employed or an employee (W-2)?
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What is their estimated monthly income after business expenses?
Include all money they receive from work minus expenses.
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What is their monthly paycheck before taxes?
This is the amount they see on your paycheck before taxes and deductions. Another way to calculate: Hourly rate x hours worked= gross pay
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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
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Dental
NONE
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Dependent #1 Age
Age
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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
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NONE
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Dependent #2 Age
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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
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Dental
NONE
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Dependent #3 Age
Age
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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
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Dependent #4 Age
Age
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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
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Dependent #5 Age
Age
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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
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Dependent #6 Age
Age
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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
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32
What is your monthly budget for health insurance?
Less than $100
$100-$200
$200-$300
$300-$400
$400-$500
$500-$700
$700-$900
$900-$1000
Over $1000
Other
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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)
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Is there any additional information you'd like us to consider?
Upload any additional documentation of anything you'd like us to consider
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If unsure about any of the questions regarding what is filed on your taxes, please upload a copy of your most recent IRS Tax Return 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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Estimated Monthly Household Income
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