PTANA Health Insurance Inquiry

Your Name* This field is required.

Prefix

First Name

Middle Name

Last Name

Suffix

Gender* This field is required.

MaleFemale

Your Travel Agency / Company Name:* This field is required.

What PTANA Chapter are you a member of?* This field is required.

Email* This field is required.Preferred email for coverage billing / communication.

example@example.com

Mobile Phone Number* This field is required.

Area Code

Phone Number

Date of Birth* This field is required.Kindly supply date of birth of primary applicant. During interview you will be asked for date of birth for everyone needing coverage. For employees, we will provide a Census Excel Spreadsheet for completion.

Date

Residential Address* This field is required.Plan offerings are based on your residential address, not your business billing address.

Street Address

Street Address Line 2

City

State

Zip Code

Country

County of Residence* This field is required.Plans offerings vary by County in your state of residence.

Coverage you are interested in:* This field is required.(Check all that apply.)

Individual / Family

Medicare

Group / Small Business (2-25 employees)

Group / Large Business (25-100 employees)

Dental

Vision

Hospital Indemnity

Disability Income

Cancer / Heart Attack / Stroke

Long Term Care

Accident

Life

Final Expense

College Funding / Planning

Do you currently have health coverage?* This field is required.

YESNO

When does your current coverage end?(If you currently have no coverage, indicate the last date you were covered. Otherwise enter the end date of your current coverage.)

Date

Reason you are looking for affordable health coverage.* This field is required.(Job change, loss of coverage, premium too high, poor network, not insured, doctor no longer accepts plan, etc.)

Job Change

Loss of Coverage

Current premium too high

Poor network

Not currently insured

Doctor no longer accepts plan

Exploring Medicare options

Other

What date would you like your health coverage to begin?

Date

Today's Inquiry Date:* This field is required.

Date

Hour

Minutes

Do you agree?* This field is required.This is our busiest time of the year, so please allow up to 1-2 business days for a response and please understand that we respond to inquiries in the order we receive them. PTANA Membership does not guarantee insurance coverage. Product availability, eligibility, underwriting and rates vary by state as well as individual circumstances and insurance company guidelines. Select "I agree" to submit your Inquiry Form.

I Agree

Please indicate that you agree and understand. * This field is required.Please type your name below. An iHealthCare Benefits Specialist will contact you ASAP to schedule a 1-on-1 appointment to review recommendations tailored to your individual needs. We thank you for the opportunity to do business with you! You can also schedule an appointment and pick a day/time that works for you on the next page.

PTANA Health Insurance Inquiry