Just like our slogan says, "We Make Insurance Suck Less", we're here to help find the best option. We understand shopping for insurance sucks, it can be confusing, which is why we work to streamline the process.

Customizing health insurance is what we do best! We strive to create a warm, pain-free environment that makes finding a plan easy, just as it should be. Please take a minute to answer some questions, this will help us expedite the process.

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What type of coverage you're interested in? *

Zip code *

Do you have employees you are looking to provide benefits for? *

How many employees do you have? *

The following information will remain secure and never be solicited or sold. We will only use this information to share details about your quotes.

Full name *

Phone *

Email *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (XXX) XXX-XXXX for assistance. You can reply STOP to unsubscribe at any time.

PRIMARY APPLICATION INFORMATION

Date of birth *

Gender at birth *

Do you use tobacco or vape? *

MARITAL STATUS

Marital status *

Does your spouse/ significant other need coverage? *

Yes

SPOUSE'S INFORMATION

Date of birth (Spouse) *

Does your spouse use tobacco *

DEPENDENTS

How many dependents do you wish to add? *

Tell us a little bit about your medical background.

Why do we ask about medical background?

Some insurance carriers apply rate increase to tobacco users. We want to be sure we provide the most accurate quotes. It may also be important to continue seeing your current healthcare provider(s). If this applies to your situation, feel free enter their names below. If not, you can leave the box blank.

List first and last name of current healthcare providers:

HOUSEHOLD INCOME

Why am I being asked this?

This information is used in solely determining whether your household qualifies for a subsidy (tax reduced premium) through the affordable care act. If not interested in inquiring about tax credits you can select "Prefer not to say" from the dropdown list.

What is the estimated annual household income for your entire household during the year coverage is requested? (Adjusted Gross Income is your total income from all sources minus specific deductions, or "adjustments," that you are eligible to take). *

Note: If you wish to opt out of quotes through the marketplace based on household income, simply skip this question.

What type of coverage do you have? *

How much are you currently paying for coverage each month? *

How soon do you want your coverage to begin? *

Did someone refer you?

Please list the name(s) of who referred us: