Pre- Qualification Biz Benefits

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Note: No plans available in Washington State.
Businesses with fewer than 5 W-2 employees may also offer this health insurance.

Complete the 11 pre-qualification questions to get started.

_________________________________________________________________________
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What state do you live in?
Please Select
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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Name* This field is required.
First Name
Last Name
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Email* This field is required.
example@example.com
6
1. Have you or any of your dependents applying for coverage been under the care of a physician currently, or within the past 5 years, for any of the following conditions: cancer, heart disease (including bypass), heart attack, heart surgery, or stroke?* This field is required.
YESNO
7
2. Have you or any of your dependents applying for coverage been homebound, incapacitated or unable to support themselves due to a medical condition in the last 5 years?* This field is required.
YESNO
8
3. Have you or any of your dependents applying for coverage been under the care of a physician currently or within the past 5 years for autoimmune or blood diseases (e.g., lupus, multiple sclerosis, anemia, HIV, hemophilia, IBS, Crohn's)?* This field is required.
YESNO
9
4. Have you or any of your dependents applying for coverage been under the care of a physician currently or within the past 5 years for organ failure or a kidney, liver, lung, heart transplant, or any type of organ support (for example, dialysis)?* This field is required.
YESNO
10
5. Are you or any of your dependents applying for coverage currently pregnant or expecting?* This field is required.
YESNO
11
6. Are you or any of your dependents applying for coverage currently being treated for any condition for which they have been hospitalized in the last 5 years?* This field is required.
YESNO
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7. Have you or any of your dependents applying for coverage been under the care of a physician currently or within the past 5 years for respiratory disorders (for example, emphysema, chronic bronchitis, COPD, or chronic pneumonia)?* This field is required.
YESNO
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8. Have you or any of your dependents applying for coverage been under the care of a physician currently or within the past 5 years for musculoskeletal disorders (for example, back disorders, muscular dystrophy, cerebral palsy, dermatomyositis, compartment syndrome, sciatica, or osteoporosis)?* This field is required.
YESNO
14
9. Have you or any of your dependents applying for coverage been under the care of a physician currently or in the past 5 years for substance abuse or dependency?* This field is required.
YESNO
15
10. Have you or any of your dependents applying for coverage been under the care of a physician currently or in the past 5 years for Type 1 Diabetes?* This field is required.
YESNO
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11. In the past 5 years, have you or anyone applying for coverage had surgery that is still being treated for? Or do you have any surgery planned soon?* This field is required.
YESNO
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Best days and times to reach you
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I confirm the information provided is accurate to the best of my knowledge.If you pre-qualify, you will be contacted to schedule a call to review your options.
YESNO
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