Qualifying Questionnaire

Please fill out the following form to help determine which coverage policy or policies would best suit your specific needs.

All information listed will be kept 100% confidential.

First & Last Name

Desired Start Date:

Zip Code

Date of Birth

Are you looking for Dental/Vision coverage as well?

Yes, Both

Yes, Dental

Yes, Vision

Neither

Are you (and/or your spouse/dependent(s) [If any] nursing any health conditions, or taking any daily prescriptions

Yes

If you answered yes to this question, please elaborate which conditions/medications apply, and to which candidate(s):

To determine if you qualify for any government subsidies within the Affordable Care Act, please list the household income and amount of household members:

If any, please list genders/dates of birth of all others needing coverage, ideal budget range, and/or any additional information that may be useful in determining which policy will best suit your situation:

Email Address

Phone Number

Please expect an initial call/text/email from myself or a direct colleague of mine.

This information will never be shared anywhere else.

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting! Please allow 24-48 hours for contact, but we will be in-touch soon. Let's get you covered!