Individual Benefits Request Form
Ian Ekdahl - ian.ekdahl@healthmarkets.com - (531) 222-7481
Name of Primary Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
City
State / Province
Postal / Zip Code
County for Mailing Address
*
County
Date of Birth
*
-
Month
-
Day
Year
Date of Birth
Gender
*
Male
Female
Estimated Household Adjusted Gross Income for 2025
*
This is used to determine potential Advanced Premium Tax Credits
Total Number of Family Members That Will Be Claimed on Your 2025 Tax Return
*
Married or Single
*
Single
Married
Are you Currently Covered?
Yes
No
If Yes:
Name of Carrier
Monthly Premium
Tobacco Use
Yes
No
List Any Benefits You Would Like to Consider
Medical
Dental/Vision
Hospital/Surgery
Cancer/Heart Attack/Stroke
Accident
Life
Are You Eligible for Employer Sponsored Coverage?
*
No
Yes - Small Employer (Less than 50 full-time employees)
Yes - Large Employer (More than 50 full-time employees)
Do You Have a Spouse/Parent Who Is Eligible for Employer Sponsored Coverage That You Could Be On?
*
No
Yes - Small Employer (Less than 50 full-time employees)
Yes - Large Employer (More than 50 full-time employees)
Coverage For:
*
Applicant Only
Applicant + Spouse
Applicant + Children
Applicant + Family
Please list all family members that you would like to cover
Spouse Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Tobacco Use
Yes
No
Dependent 1 Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Tobacco Use
Yes
No
Dependent 2 Name (If Applicable)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Tobacco Use
Yes
No
Dependent 3 Name (If Applicable)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Tobacco Use
Yes
No
Dependent 4 Name (If Applicable)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Tobacco Use
Yes
No
List any prescriptions you need covered:
Please, include the name, dosage, and if it's a tablet or capsule
List any Providers you need covered:
Doctor's Full Name or Hospital/Clinic Name
Submit
Should be Empty: