Individual Benefits Request Form
Ian Ekdahl - ian.ekdahl@healthmarkets.com - (531) 222-7481
Thank you for taking the time to complete this quick form! I look forward to helping you find a high-quality affordable health insurance plan that fits your needs.
If you were referred to me, who referred you?
First & Last Name of Who Referred You
Back
Next
Save
Household Information
Name of Primary Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date of Birth
What is your height AND weight?
*
Height and Weight
Gender
*
Male
Female
Tobacco Use
*
Yes
No
What is your budget range?
*
What price range are you ideally trying to stay within?
Address
*
Street Address
City
State / Province
Postal / Zip Code
County for Mailing Address
*
County
Estimated Household Adjusted Gross Income for 2026
*
This is used to determine potential Advanced Premium Tax Credits
Total Number of Family Members That Will Be Claimed on Your 2026 Tax Return
*
Married or Single
*
Single
Married
Are you Currently Covered?
*
Yes
No
If Yes:
Name of Carrier
Monthly Premium
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
Height and Weight - Spouse
Height and Weight
Will you claim all of the dependents listed below as dependents on this year's tax return?
*
Yes
No
I Don't Have Any Dependents
Dependent 1 Name (If Applicable)
First Name
Last Name
Gender
Male
Female
Date of Birth
/
Month
/
Day
Year
Date
Tobacco Use
Yes
No
Height and Weight
Height and Weight
Dependent 2 Name (If Applicable)
First Name
Last Name
Gender
Male
Female
Date of Birth
/
Month
/
Day
Year
Date
Tobacco Use
Yes
No
Height and Weight
Height and Weight
Dependent 3 Name (If Applicable)
First Name
Last Name
Gender
Male
Female
Date of Birth
/
Month
/
Day
Year
Date
Tobacco Use
Yes
No
Height and Weight
Height and Weight
Dependent 4 Name (If Applicable)
First Name
Last Name
Gender
Male
Female
Date of Birth
/
Month
/
Day
Year
Date
Tobacco Use
Yes
No
Height and Weight
Height and Weight
Dependent 5 Name (If Applicable)
First Name
Last Name
Gender
Male
Female
Date of Birth
/
Month
/
Day
Year
Date
Tobacco Use
Yes
No
Height and Weight
Height and Weight
Dependent 6 Name (If Applicable)
First Name
Last Name
Gender
Male
Female
Date of Birth
/
Month
/
Day
Year
Date
Tobacco Use
Yes
No
Height and Weight
Height and Weight
Back
Next
Save
Health Questionnaire
Please, provide as much detail in your answers as possible so that I can better understand your health needs.
List any prescriptions you or anyone in the household will need covered:
Please, include the name, dosage, and if it's a tablet or capsule
List any Providers you or anyone in the household would like to have in-network with the plan:
Doctor's Full Name or Hospital/Clinic Name
Does anyone in the household have any pre-existing health conditions?
List any health condition you are currently monitoring, taking medication for, or being treated by a medical professional for.
Save
Submit
Should be Empty: