Under-65 Health Insurance Quote Intake
Answer questions about your coverage needs, household, and current situation to request a quote.
Coverage
Reason for seeking coverage
Please Select
Losing employer coverage
COBRA ending or too expensive
Self-employed or currently uninsured
Medicaid or CHIP ending
Aging off a parent's plan
Moving or changing states
Divorce or legal separation
Marriage or new baby
Current plan is too expensive
Open Enrollment or renewal
Other
When do you need coverage to start?
*
Within 0-1 month
In 2-6 months
More than 6 months from now
Not sure
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
County
*
ZIP Code
*
Primary Applicant
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Sex
Male
Female
Marital Status
Please Select
Single
Married
Domestic Partnership
Divorced
Separated
Widowed
Prefer not to answer
Height (total inches)
5 feet 10 inches = 70 total inches.
Weight (pounds)
Enter weight in pounds.
Tobacco or nicotine use in the past 6 months?
*
Yes
No
Is anyone applying for coverage currently pregnant?
Yes
No
Household and Discounts
How many people will be on your federal tax return this year, including you, your spouse, and dependents?
*
Best estimate of total household income for the full calendar year
*
Include income already earned plus expected income for the rest of the year. An approximate dollar amount is fine if you’re unsure.
Are you planning to retire in 2027 or 2028 and requesting health insurance quotes for that year?
*
Yes
No
Best estimate of total household income for the full calendar year you retire
*
Include income already earned plus expected income for the rest of the year. An approximate dollar amount is fine if you’re unsure.
Spouse or Significant Other
Do you need to add a spouse or significant other?
*
Yes
No
Spouse or significant other first name
Spouse or significant other last name
Spouse or significant other date of birth
-
Month
-
Day
Year
Date
Sex
Male
Female
Does this person need health coverage?
Yes
No
Tobacco or nicotine use in the past 6 months?
Yes
No
Height (total inches)
5 feet 10 inches = 70 total inches.
Weight (pounds)
Enter weight in pounds.
Children and Dependents
How many children or dependents do you need to add?
*
None
1
2
3
4
5 or more
Child 1 - First name
Child 1 - Last name
Child 1 - Date of birth
-
Month
-
Day
Year
Date
Child 1 - Sex
Please Select
Male
Female
Child 1 - Does this child need health coverage?
Yes
No
Child 1 - Tobacco or nicotine use in past 6 months?
Yes
No
Child 2 - First name
Child 2 - Last name
Child 2 - Date of birth
-
Month
-
Day
Year
Date
Child 2 - Sex
Please Select
Male
Female
Child 2 - Does this child need health coverage?
Yes
No
Child 2 - Tobacco or nicotine use in past 6 months?
Yes
No
Child 3 - First name
Child 3 - Last name
Child 3 - Date of birth
-
Month
-
Day
Year
Date
Child 3 - Sex
Please Select
Male
Female
Child 3 - Does this child need health coverage?
Yes
No
Child 3 - Tobacco or nicotine use in past 6 months?
Yes
No
Child 4 - First name
Child 4 - Last name
Child 4 - Date of birth
-
Month
-
Day
Year
Date
Child 4 - Sex
Please Select
Male
Female
Child 4 - Does this child need health coverage?
Yes
No
Child 4 - Tobacco or nicotine use in past 6 months?
Yes
No
Child 5 - First name
Child 5 - Last name
Child 5 - Date of birth
-
Month
-
Day
Year
Date
Child 5 - Sex
Please Select
Male
Female
Child 5 - Does this child need health coverage?
Yes
No
Child 5 - Tobacco or nicotine use in past 6 months?
Yes
No
Additional children or dependent information
Work and Current Coverage
Current work status
*
Employee
Self-employed
Not currently working
Is health insurance offered through an employer to anyone applying?
*
Yes
No
Not sure
Monthly employee-only premium
Monthly family or dependent premium
What coverage do you have now?
*
Please Select
Marketplace
Employer plan
Private/individual
Medicaid/CHIP
Short-term
COBRA
None
Other
Is COBRA available or active?
*
Yes
No
Not sure
What is the monthly COBRA cost?
When does your current coverage end, or when did it end?
*
-
Month
-
Day
Year
Date
Health Needs and Preferences
Doctors or specialists that must be in network (include clinic or city)
Preferred hospital or health system
Medication types used
None
Blood pressure
Cholesterol
Anxiety or depression
Diabetes
Insulin
Blood thinner
Heart medication
Asthma/COPD inhaler
Thyroid
Pain medication/opioid
Autoimmune/biologic
Seizure medication
Cancer treatment
HIV medication
Weight-loss medication
Other
Higher-cost medications used
None
Ozempic
Wegovy
Mounjaro
Zepbound
Rybelsus
Trulicity
Jardiance
Farxiga
Insulin
Eliquis
Xarelto
Entresto
Humira
Enbrel
Stelara
Skyrizi
Rinvoq
Dupixent
Other
Major health conditions, ongoing treatment, or planned procedures
What matters most in your health plan?
Lowest premium
Lower deductible
Predictable copays
Keep specific doctors/hospitals
Prescription coverage
Broad network
HSA eligibility
Comfortable monthly budget
Other Coverage Interests
What monthly premium would feel comfortable for your household?
Do you currently have any of these policies?
*
Yes
No
Which coverage interests apply to you?
Health insurance only
Dental
Vision
Life insurance
Critical illness/cancer
Accident
Hospital indemnity
Disability
Long-term care/home health
Final expense
Current policies list
Current amount of life insurance coverage
Anything else you would like us to know
Submit
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