Health Insurance Assessment
What type of health insurance are you seeking?
*
Individual
Family (with spouse)
Family (with children)
Group (business)
Age:
If family, please input spouse age after your age
Group insurance (business only):
Number of employees
State (location)
*
Health insurance status:
*
Uninsured
Insured
Where is your insurance currently from:
*
Employer-Sponsored
Private Health Insurance
Marketplace Plan
Healthshare
Cobra
No Insurance
On average, how often do you visit a doctor per year?
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0-1 times
2-3 times
4-6 times
7+ times
Do you currently take prescription drugs regularly?
*
Yes
No
Are you interested in any specific coverage areas (check all that apply)?
Preventative care
Specialist visits
Virtual care (telemedicine)
Mental health services
Maternity care
Prescription drug coverage
All the above
Other
What are you currently paying in premium for your health insurance? (put $0 if you are uninsured)?
*
Are you interested in learning how to pay $0 out-of-pocket for care?
*
Yes
No
Contact Info
Name
*
Email Address
*
example@example.com
Submit
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