Let's talk

First Name*

Last Name*

Email*

Address*

Do you currently have insurance?*

Yes

Other

If yes, how much are you currently paying for your premiums and what is your deductible?

Who needs coverage? (please include name, age & DOB)*

Any tobacco use in the last 2 years?*

Yes

Do you take any regular medications? If yes, please list the medicine and reason*

Any hospitalization or major diagnosis in the last 5 years? If yes, please include details*

Any drug or alcohol treatment in the last 4 years?*

Yes

Any history of cancer, heart attack, stroke, insulin use, HIV/AIDS in the last 5 years?*

Has a doctor recommended a surgery in the next 12 months?*

Yes

Do you have any upcoming or ongoing maternity needs?*

Have you been prescribed medications or medical equipment in the last 5 years? (CPAP, nebulizers, etc)*

Do you have a network preference?

PPO

HMO

EPO

Not sure

Do you have any specific doctors you would like to keep seeing or be willing to pay more for?*

When do you want coverage to start?*

Do you have a qualifying event?

Yes

Not sure

The questions below are for ACA compliance (if interested)

Household size

Approximate annual income

Occupation

Married?

Yes

File taxes jointly?

Yes

Call

714-619-1784

bottom of page