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
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Household Information
Name of Primary Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
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 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
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
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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.
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Book Your Free Insurance Consultation With Me
Use the calendar link below to choose the date and time that you'd like me to call you to go over your health insurance options. The meeting is 100% free. There is no cost or obligation to you.
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