New Policy - Health - RiskRevu.com

First Name - Insured 1

What is your first name?

Last Name - Insured 1

What is your last name?

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What is your full name?

What is your gender?

What is your preferred phone number?

Email

Please enter your email address.

Please enter your address.

Street Address Address Line 2 City State ZIP Code

Which county do you live in?*

Which county do you live in? (required)

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What is your date of birth?

Date of Birth - Insured 1

What is your date of birth?

What is your occupation?

Tobacco use?

Do you use tobacco?

Yes
No

Other coverages?

Please select the coverages you are interested in.

Dental
Vision
Neither dental nor vision. Health only.

Any dependents?

Do you have any dependents? Please include all dependents (part of the subsidy calculation) and indicate whether they need coverage below. (Select all that apply.)

Spouse
Child/Children
Other
None

Spouse information

Please provide the following information for your spouse.

Full Name	Gender	Date of Birth	Tobacco Use (Y/N)	Seeking Coverage (Y/N)

Child/Children Information

Please provide the following information for your child/children.

Full Name	Gender	Date of Birth	Tobacco Use (Y/N)	Seeking Coverage (Y/N)

Please provide the following information for your other dependent(s).

Full Name	Gender	Date of Birth	Tobacco Use (Y/N)	Seeking Coverage (Y/N)

Triggering Event

Has any of the following occurred in the last 60 days? (Select all that apply)

Lost employer coverage
Marriage
Divorce
Added a child to your family (birth or adoption)
Moved
None

No Triggering Event

You may NOT be eligible for a Marketplace plan at this time because you selected "None" in the previous question. Would you like to explore whether a short-term plan is an option for you? (Note: Short-term plans do not provide coverage for pre-existing conditions.)

Yes
No

Pre-existing condition?

Are you currently being treated for any medical condition(s)?

Yes
No

What is your estimated household income for the current year (modified adjusted gross income)? This information is used to determine if you are eligible for a government subsidy.

Please enter your employer name.

Please enter your employer phone number.

Please enter your employer address.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you previously been covered by a marketplace plan?

Yes
No

Documents and Comments

Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, appraisals, etc...)

Drop files here or

Accepted file types: jpg, gif, tiff, png, pdf, Max. file size: 128 MB, Max. files: 5.

Please enter any additional remarks in the space below.

How did you hear about us?

Please share who referred you to us.

Please share what you typed into Google.

Please share how you heard about us.

Consent*

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

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Health Insurance Form

Documents and Comments

Aida Rodriguez

RiskRevu^TM Newsletter

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Health Insurance Form

Documents and Comments

Aida Rodriguez

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter