Health Insurance Estimate for Young AdultsThis form will help us provide you with estimates in health insurance for you and your family members. Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * What is your date of birth? * MM DD YYYY Do you currently have Health Insurance? Yes No Do you have a spouse? Yes No If yes, what is your spouse's name? Spouses date of birth MM DD YYYY Do you have any dependants? Yes No If yes, please provide names, gender and dates of birth. Are you or your spouse Self Employed? Yes No Is Health Insurance offered through your spouse's employer? Yes No Do you have any Health Reimbursement Arrangements with your employer? Yes No If yes, please describe. What is your estimated household income for Tax Year 2023? List any Doctors, Specialists, Hospitals or Clinics that are important to you. List any medications that you would like to be covered. Please list the benefits that are important to you. Low premium Low deductible/max out of pocket Strong network Low co-pays Low medication costs Mental Health (therapy) Mental Health (prescription medication) Holistic Practices Please select any additional coverages you are interested in. Dental Vision Accident coverage Catastrophic Gap Coverage Life Insurance Disability Insurance Other Are you interested in helping your family, friends, coworkers, and/or followers get health insurance? Please list any comments, concerns or instructions here. Thank you!
