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Family Information - Instant Quote Request Form

Individual Information

Family Quote
Step One Insurance QuoteEnter the information requested below, along with the Age(s) of insured plan members to be included in this proposal.
NOTE: Items with a * are required
First Name:
Last Name:
Insurance Quote
Email: *
Daytime Phone:
Address:
City:
State:
 
Zip: *
 
 
Gender
Date of Birth
Height
Weight
  
Tobaco User?
Full-time
Student?
  
Applicant:
/ /
 
 
Spouse:
/ /
 
 
Child:
/ /
 
 
Child:
/ /
 
 
Child:
/ /
 
 
Child:
/ /
 
 
Child:
/ /
 
 
    Requested Effective Date July    August    September
Maternity Coverage
What is your current health plan premium? (optional)
 $ month
Show All (Plans With & Without Maternity Coverage)
      
Only Plans With Maternity Coverage      
No Maternity Coverage
      
Medical Plan Type          
Standard Individual & Family Coverage
  
Short-Term, Up to 12 Months of Temporary Coverage
  

Online Quote Instruction GuideOnline Quote Instruction Guide

Family Members To Be Insured

You can apply for any one of the following combinations of family members:

  • Single adult
  • Couple - you and your spouse
  • Family - you, your spouse and one or more children
  • Single parent household - parent and one or more children
  • Single child
  • More than one child
The gender and age/date of birth of each person is also required.

When entering a child and/or children only, enter the age/date of birth in the child boxes. Enter any additional children in the appropriate child blocks. Rate computations for child/children only plans vary by carrier. Some insurance companies have specific rates for youth plans and other insurance companies base rates for children on the age of either the youngest or oldest child.

Age/Date of Birth - The age or date of birth for each family member that is to be insured.

Tobacco Usage - For each adult that is to be insured, please check the box if they are a tobacco user. By default, all adults are assumed to NOT be tobacco users.

Medical Plan Types

Medical, standard long-term coverage
Most people select this form of coverage. This type of coverage can be renewable for multiple years and can provide continuous claims coverage over a long period of time. Most plans of this type cover both major medical expenses (e.g., hospitalization and surgeries) and routine medical expenses (e.g., office visits and annual exams), subject to deductibles and co-payments or co-insurance.

Short-term, up to 12 months temporary coverage
Short-term health insurance is a temporary health insurance plan (typically 1 to 12 months) and should NOT be used as a substitute for standard, long-term health insurance.

Short-term health insurance may be right for you if you are:
  • Between jobs
  • Waiting for coverage from another health plan to start
  • Laid off
  • On strike
  • A recent college graduate
  • A seasonal employee
BUT, please keep in mind the following:
  • Short-term medical plans are intended as interim or "gap" coverage, i.e., for people who know, with certainty, that they will have standard, long-term coverage (or coverage through an employer) at a future date.
  • Short-term plans are designed to provide protection from unforeseen illness or injury; they are not meant to cover routine exams, preventive care, dental or eye care, or immunizations.
  • Short-term plans are exempt from HIPAA legislation. This means that when issuing a Short-term medical policy, insurance carriers do not have to: guarantee renewal, guarantee issue, or waive the pre-existing condition limitation for federally eligible individuals.
  • Most importantly, short-term medical plans provide coverage for a limited time frame only. Once this time frame ends, you may or may not be able to buy additional health insurance, depending on your health at that point in time.

IF YOU ARE UNSURE THAT YOU WILL HAVE STANDARD, LONG-TERM HEALTH INSURANCE (OR INSURANCE THROUGH AN EMPLOYER) WITHIN 12 MONTHS, WE STRONGLY RECOMMEND THAT YOU VIEW PLANS FOR STANDARD, LONG-TERM HEALTH COVERAGE NOW, BEFORE THERE IS AN ADVERSE CHANGE IN YOUR HEALTH CONDITION.