New Client: Health Insurance Quote Information Request Questionnaire

Please note, this is for individual health insurance, if you are seeking a group health insurance quote, please contact us at:

531-222-2120

First Name *

Last Name *

Email *

Phone *

Address *

Do You Have Current Health Insurance? *

Check All Recent or Upcoming Life Events that Apply: *

Current Health Insurance is Ending Soon

Previous Health Insurance Coverage Recently Ended

Recent or Upcoming Marriage/Divorce

Recent or Upcoming Family Addition (Birth, Adoption, etc)

Recent or Upcoming Move

Job Change

Other Significant Life Event

None of These Apply

Please Note: Marketplace plans have special life event eligibility requirements outside of Open Enrollment.

Primary Applicant Information

This is your information. If you are not seeking coverage and are only helping someone else out in preparation for their application, please contact our office for instructions:

531-222-2120

[email protected]

Date of birth

Do You Use Tobacco? (Primary Applicant) *

Are You a Parent to Child (Primary Applicant) *

Yes

Please only check "Yes" if you will be claiming the child as a dependent in the tax year in which you are applying for coverage.

Are You Pregnant? (Primary Applicant) *

Yes

Are You or Will You Be Married by the End of the Calendar Year in Which You are Applying for Coverage? *

Yes

Please note that any tax credits will only be based on the tax household. If married, you must file jointly to qualify for the tax year enrolled. If counting dependents for credit calculations, you must be eligible and claim them on your income taxes for the tax year health coverage is being enrolled for.

Prescription Medications - Primary Applicant

Doctors, Specialists, and Therapists - Primary Applicant

Is Anyone Else Applying for Coverage? *

Yes

Second Person Applying for Coverage

Full Name - Person 2

Date of Birth - Person 2

Tobacco Use - Person 2

Yes

Parent to Child - Person 2

Yes

Pregnant - Person 2

Yes

Prescription Medications - Person 2

Doctors and Specialists - Person 2

Is Anyone Else Applying for Coverage?

Yes

Third Person Applying for Coverage

Full Name - Person 3

Date of Birth - Person 3

Tobacco Use - Person 3

Yes

Pregnant - Person 3

Yes

Parent to Child - Person 3

Yes

Prescription Medications - Person 3

Doctors and Specialists - Person 3

Is Anyone Else Applying for Coverage?

Yes

Fourth Person Applying for Coverage

Full Name - Person 4

Date of Birth - Person 4

Tobacco Use - Person 4

Yes

Pregnant - Person 4

Yes

Parent to Child - Person 4

Yes

Prescription Medications - Person 4

Doctors and Specialists - Person 4

Is Anyone Else Applying for Coverage?

Yes

Fifth Person Applying for Coverage

Full Name - Person 5

Date of Birth - Person 5

Tobacco Use - Person 5

Yes

Pregnant - Person 5

Yes

Doctors and Specialists - Person 5

Prescription Medications - Person 5

Is Anyone Else Applying for Coverage?

Yes

Sixth Person Applying for Coverage

Full Name - Person 6

Date of Birth - Person 6

Tobacco Use - Person 6

Yes

Pregnant - Person 6

Yes

Doctors and Specialists - Person 6

Prescription Medications - Person 6

Is Anyone Else Applying for Coverage?

Yes

Please Note: If anyone else is applying for coverage, please include their information in the "Additional Information" field on the next screen.

Is anyone in your tax household who is not applying for coverage? *

Estimated Gross Annual Household Income For 2025 *

Not sure how to calculate your estimated income? See the Marketplace for additional information.

Additional Information

Are You Interested in Quotes for Dental Insurance?

Yes

Dentist(s)

Are You Interested in Quotes for Vision Insurance?

Yes

Optometrist(s)

I agree to the Privacy Policy provided by Redinbaugh Enterprises, LLC and its subsidiaries and representatives. By providing my contact information, I also agree to receive emails, calls, and text messages from the business.