Insurance Inquiry Form

This form provides the necessary information to be able to advise you. It is not shared with any other entity and/or used for any other purpose. PLEASE NOTE: Assistance is only available to current members. Membership does not guarantee eligibility for insurance policies. We advise based on each member's situation. Product availability, rates, and eligibility vary by state, individual circumstances, and insurance companies' guidelines. There are no major medical health insurance options available in AK, CA, CT, DC, HI, MA, ME, NH, NJ, NY, RI, VT, and WA, other than employer sponsored groups and the individual ACA/Obamacare system due to state restrictions.
*Required
NAME OF ASSOCIATION?*

ARE YOU A CURRENT MEMBER?*

ARE YOU ELIGIBLE FOR AND/OR RECEIVING MEDICAID OR A MARKETPLACE SUBSIDY?*

MEMBER INFORMATION
FIRST & LAST NAME*
RESIDENTIAL ADDRESS*
CITY*
STATE*
ZIP*
COUNTY*
EMAIL*
PHONE*
GENDER*
DATE OF BIRTH*
TOBACCO USER?*
HEIGHT & WEIGHT*
ANY PRE-EXISTING HEALTH CONDITIONS IN THE LAST 5 YEARS?*
If yes, please include the details (diagnoses, medications, etc.).

SPOUSE INFORMATION (IF TO BE INCLUDED)
FIRST & LAST NAME
GENDER
DATE OF BIRTH
TOBACCO USER?
HEIGHT & WEIGHT
ANY PRE-EXISTING HEALTH CONDITIONS IN THE LAST 5 YEARS?
If yes, please include the details (diagnoses, medications, etc.).

CHILDREN INFORMATION (IF TO BE INCLUDED)
Please include the full name, gender, DOB, height, weight, and any health conditions for each child.
CHILD 1
CHILD 2
CHILD 3
CHILD 4
CHILD 5

ANYONE PREGNANT?*
If yes, please include the due date.

INSURANCE PRODUCTS OF INTEREST*

REASON FOR DESIRING ASSISTANCE*
(Job change, premium too high, poor network, not insured, etc.)

IF NOT INSURED, HOW LONG HAVE YOU BEEN WITHOUT?*
(Type N/A if you are insured)

DESIRED EFFECTIVE DATE*

I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS OF SERVICE AT THE TOP OF THE PAGE* (Type "Yes" in order to proceed)

PLEASE PRESS SUBMIT AND WE WILL CONTACT YOU WITHIN TWO BUSINESS DAYS.