Individual Health Insurance Quote (Multiple Companies)

Individual Health Insurance Quote

Name of Insured
First Last
Address
Street Address City State ZIP Code
Phone
Email
Desired Effective Date
Does your household income exceed $47,000 per year?
Have you had Qualifying Life Event (QLE)
Select What was Qualifying Event Qualifying Event Date

A qualifying event is an event that triggers a special enrollment period for an individual or family to purchase health insurance outside of the regular annual open enrollment period. ... a permanent move to an area where different health plans are available (as long as you already had coverage prior to the move). There are 4 basic types of qualifying life events. (The following are examples, not a full list.) Loss of health coverage Losing existing health coverage, including job-based, individual, and student plans Losing eligibility for Medicare, Medicaid, or Children's Health Insurance Program (CHIP) Turning 26 and losing coverage through a parent’s plan Changes in household Getting married or divorced Having a baby or adopting a child Death in the family Changes in residence Moving to a different ZIP code or county A student moving to or from the place they attend school A seasonal worker moving to or from the place they both live and work Moving to or from a shelter or other transitional housing Other qualifying events Changes in your income that affect the coverage you qualify for Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder Becoming a U.S. citizen Leaving incarceration (jail or prison) AmeriCorps members starting or ending their service
Individual Information
Current Occupational Status Job Title Employer's Specific Industry are you an Office Employee Only
Spouse/Domestic Partner Information
Spouse/Domestic Partner Job Title Employers Specific Industry Are you an Office Employee Only (Yes or No)
Benefit Information
Desired Effective Date Deductible
Are You Currently Pregnant?
If Pregnant, What is Delivery Date
List Significant Medical History:
PLAN DESIRED (Check All You Are Interested)
- Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Health Savings Account (HSA)
- Catastrophic Coverage (only if under 26 or have qualifying hardship)
Current Coverage
Current plan Type Current Premium Current Annual Deductible
What Insurance Do You Have Currently
Current plan Type Current Premium Current Annual Deductible
Census Information for those to be insured (Click on (+) to add additional)
Relationship to Insured Gender Birthdate
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Max. file size: 20 MB.

Individual Health Insurance Quote (Multiple Companies)

Individual Health Insurance Quote

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Select	What was Qualifying Event	Qualifying Event Date

Current Occupational Status	Job Title	Employer's Specific Industry	are you an Office Employee Only

Spouse/Domestic Partner Job Title	Employers Specific Industry	Are you an Office Employee Only (Yes or No)

Desired Effective Date	Deductible