Health Intake

Second: Tell us about you

Plan premiums are calculated using a combination of your household size and income. Together, these play a large role in determining what benefits you are eligible for and ensuring that you don't pay more than you have to.
Seeking CoverageFemaleMaleTobacco UserPregnant
Name*

First NameLast Name
Birthdate*

MonthDayYear
Social Security Number
For a quote, this field is completely optional. Health insurance carriers need your social to properly bill medical claims. By completing this field now, you save a step later, when you select a plan to enroll.
Address

Street Address

County

CityState

Zip Code (Five digit)
Email*

Confirmation EmailConfirm Email
Phone Number
These next questions are used to calculate your household size according to the IRS.

Include the following:
- Spouse
- Adult children over 18 that you wish to cover by this plan
- ALL dependents that you will claim on your taxes.
You will then check "seeking coverage" next to only those who you want to be enrolled.
Are you married?

YESNO
Enter your spouse's information.
Do you have any dependents?

YESNO
Enter your dependent's information.

Four: Tell us about your income

**Check the "income type" dropdown for each section to see if any apply.** The GROSS INCOME section counts your before tax income on any income from sources like wages, retirement income, unemployment, and disability income. The NET INCOME section is asking about any profit(or loss) from sources like businesses, rentals, selling property, and earning interest/dividends.
2023 GROSS (Before Tax) Income Sources
2023 NET (After Tax) Income Sources
Additional Comments

Plan Recommendations For You

Health insurance isn't one size fits all. We will use the entered information to make recommendations uniquely suited to your needs.

Upon clicking submit, check your inbox for next steps.
You must agree to the following terms before you click submit*

I understand that by clicking submit below, I am attesting that the information provided is true and correct to the best of my knowledge.I understand that THIS IS NOT an application for insurance. By clicking submit, my expectation is that SnapHealth is legally acting in my best interest, I am requesting a personalized recommendation for insurance, and I expect to receive a recommendation that meets my needs by considering my situation against all plans available in my area.I understand that SnapHealth is an independent broker that contracts with all major carriers under national license 16120334, and they will never sell my information.I have read and agree to the SnapHealth Terms of Use and Privacy Policy.
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All of the above terms MUST be selected (green) before you can proceed
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What can you expect?