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Preliminary Insured Information Submission Form. This is not issuance of health insurance. You must review a formal application with a LIVE Health Insurance Agent to determine your needs and eligibility. NOTE: No Fees will ever be collected, unless by a licensed agent upon you authorizing a contract for health insurance services.
Your Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a Qualifying Life Event? (For SEP)
*
Please Select
OPEN ENROLLMENT (Nov 1-Jan 15)
Loss of Health Coverage (such as job based plans, individual plans, student health insurance, Medicaid, CHIP, or medicare Part A)
Changes in Household ( Getting married, Having a baby, adopting a child, getting divorced or legally separated, death of someone.
Changes in residence
Employer Offers HRA
Becoming a US Citizen
Leaving Incarceration
Gaining membership in a federally recognized tribe
No, but I'd like to see what my options are
Do you currently maintain an active bank account? A valid account may be required by insurance carriers for premium payment purposes, if applicable.
*
Yes
No
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Health Insurance LIVE Quote Request
Insured Information
Applicant Name
*
First Name
Last Name
Marital Status
*
Single
Married
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Male
Female
Tobacco?
*
Yes
No
Height (ft' in")
*
Weight (lbs)
*
Occupation:
*
Annual Household Income
*
List all prescribed medication taken, how often, for what reason, include current medical condition or medical history: including heart, stroke, cancer, injuries, ongoing treatments or treatment recommendations pending.
*
Please list first and last name of Dr's if any
Do you wish to apply a spouse for coverage? If no, Click Next.
*
Yes
No
Spouse Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Gender
*
Male
Female
Height (ft' in")
*
Weight
*
Tobacco?
Yes
No
Occupation:
List all prescribed medication taken, how often, for what reason, include current medical condition or medical history: including heart, stroke, cancer, injuries, ongoing treatments or treatment recommendations pending.
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Dependent Info
Do you have any dependents you would like to apply for coverage?
*
Yes
No
Dependent Information
*
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General Health Questions
Please answer to the best of your capability for accuracy in determining the best plan for you.
Are currently insured by a major medical plan, shared health plan, or Obamacare?
*
Yes
No
Not Sure
List your current insurance providers name.
Provide your effective date needed by:
*
Have you been hospitalized in the past 24 months?
*
Yes
No
Do you have any diagnosed heath issues?
*
Please Select
Cancer
Heart Attack
Stroke
Kidney Failure
Diabetic
Major organ transplant
Illness Induced Coma
Other(Will provide context during meeting)
None
If you weren’t able to work because of an accident or illness, how long could you or your family manage financially?
*
Less than a month
1-3 Months
3-6 Months
More than 6 months
I'm not sure
If you were hospitalized due to an accident, would you rather receive:
*
$20,000
$15,000
$10,000
If you were diagnosed with a critical illness, would you rather receive:
*
$100,000
$50,000
$10,000
How much life insurance do you have?
*
Some through my employer
Some privately
None
How ready are you in making a health care insurance decision?
*
It is urgent that I get coverage and am ready to move forward.
I would like to schedule a virtual appointment to answer my questions.
I am currently shopping for rates.
Were you referred to us by someone?
*
Yes
No
Please provide the name of the person who referred you, (if applicable).
Referee Email
example@example.com
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Schedule an Appointment
Choose a time to meet with your agent over the phone.
Appointment
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Submit
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