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Get Your Customized Health Coverage Quote
1
What type of health plan are you looking for?
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Individual
Individual with spouse
Individual with Family
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2
What are you looking for in your health plan?
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Choose the 2 most important ones for you
A low deductible
Low monthly premiums
Keep my current doctor
Save money
Prescription drug coverage
Nationwide coverage
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3
What is your Zip Code
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4
What is your Date of Birth?
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5
What is your spouse's Date of Birth?
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6
Please list the Date of Birth and Sex of Every Individual Looking For Coverage
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Add the name of each individual next to each entry
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7
What is your Height?
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8
What is your spouse's Height?
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9
Please List the Height of Every Individual Looking For Coverage
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Add the name of each individual next to each height
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10
What is your Weight?
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11
What is your spouse's Weight?
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12
Please List the Weight of Every Individual Looking For Coverage
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Add the name of each individual next to the weight
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13
Do you have a pre-existing condition?
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Yes
No
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14
Do you or your spouse have a pre-existing condition?
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Yes
No
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15
Do you or anyone in your family have a pre-existing condition?
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Yes
No
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16
Which conditions? Choose all that apply.
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Cancer
Diabetes
Heart Attack
Stroke
Kidney Failure
Arthritis
Other
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17
Are You Currently On Any Medication?
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Yes
No
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18
Are You or Your Spouse Currently On Any Medication?
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Yes
No
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19
Are You or Anyone In Your Family Currently On Any Medication?
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Yes
No
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20
Please provide the name of all the medications you're taking.
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21
Please provide the name of all the medications
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Add the name of each individual next to each medication
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22
Have You Had Any Surgeries In The Last 10 Years?
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Yes
No
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23
Have You or Your Spouse Had Any Surgeries In The Last 10 Years?
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Yes
No
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24
Has You or Anybody in you Family Had Any Surgeries In The Last 10 Years?
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Yes
No
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25
Please list all major surgeries within the last 10 years.
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26
Please list all major surgeries within the last 10 years
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Add the name of each individual next to each surgery
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27
Do You Smoke?
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Yes
No
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28
Do You or Your Spouse Smoke?
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Yes
No
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29
Do You or Anyone in Your Family Smoke?
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Yes
No
Other
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30
Are You Currently Insured?
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Yes
No
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31
Who are you currently insured with?
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32
What is your current monthly premium?
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This information will help us look for a plan that could save you money
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33
What is your monthly budget for a health plan
This will help us identify health plans that meet your goal
$200-$300 (or less)
$300-$500 (or less)
$500-$800 (or less)
$800+
I care more about the quality of the plan then the cost
I want a plan that does not leave me financially exposed
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34
What is your name?
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First Name
Last Name
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35
What is your best email to receive this quote?
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Please provide your best email
example@example.com
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36
In Case We Have Any Questions, Please Provide Your Phone Number
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Area Code
Phone Number
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