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Plan Finder                                

The Plan Finder provides you with cost, and coverage information based on your specific needs. This is not an application for insurance. Please complete the following information, and click on the submit form at the bottom of the page. All requests are processed the day they are received. No agents will call unless requested below.

General Information:   

Date of Birth: -- mm/dd/yy
Sex: Male Female
Married or Single: Married Single
Spouse to be covered ... ? Yes No
Spouse; Date of Birth: -- mm/dd/yy
Children to be covered? Yes No
Number of children: 0 1 2 3 4 5
Self-employed? Yes No
Occupation?
Your current health provider?
Your current health plan? Employer Sponsored Individual
Under COBRA None
Where do you Live: Twin City 7 County Area
Outstate

Outstate; Specify County:

Plan Preferences: Please provide the following information so that we may provide you information on a plan that most closely fits your needs. Choose one answer for each. 5 = "very important" , and a 1 = "not important".

Choice of Doctor? 1 2 3 4 5
Preventative Care Coverage? 1 2 3 4 5
Pregnancy Coverage? 1 2 3 4 5
Prescription Drug Card? 1 2 3 4 5
Chiropractic Coverage? 1 2 3 4 5
Eye Exam Coverage? 1 2 3 4 5
Having the best possible coverage? 1 2 3 4 5

Having the least expensive?

 1 2 3 4 5

How long will you need coverage?

 0-3 Months 3-12 Months 1+ Years
 

I would like information on HSA Plans:

 Yes No

Personal Information:

First Name:

Last Name:

Company:
(if applicable)
Address:
Address (cont.):
City:
State:

Zip/Postal Code:

Work Phone:

Have Representative
 Call Me:

Yes No

E-mail:

Do any applicants have any pre-existing health conditions?

Please include information on pre-existing conditions or any other relevant items

Click on "Submit Form". You should receive your information in 2-3 business days. Please be sure to include e-mail address or work phone number should any information be incomplete.

    

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