Health Insurance Quote Request

Where are you located?* This field is required.

State

Zip Code

Country

Tell me about your situation!Please check all that apply.

Lost or losing health coverage

Change in household size

Change in primary place of living

Change in eligibility

Nothing new happening

Other situations

Did any of the below household changes occur after 06/24/2022?

I got married

I had a baby

I gained(or became a dependent)

I got divorced or legally separated

A death in the family

Moved to a new zip code or county

I moved to NY or CA

I gained Citizenship or lawful presence

I am released from incarceration

None of these apply

Do any of the below situations apply to you?

I missed the 60 day window due to COVID-19

I was enrolled in the wrong plan

I'm a survivor of domestic abuse/violence or spousal abandonment

I missed open enrollment due to a serious medical condition or natural disaster

I became a dependent of someone else or gained a new dependent due to a court order

None of these apply

I became ineligible for premium free Medicare Part A coverage.

YESNO

I became ineligible for Medicaid or CHIP.

YESNO

I was denied eligibility for Medicaid or CHIP - Did you apply for Medicaid or CHIP coverage during Open Enrollment?

YESNO

Did you lose coverage on or after 6/24/2022 or do you expect to lose it by 10/22/2022?

YESNO

How many people are in your tax household?* This field is required.This is the number of people you put on your tax return.

Estimate your last year's household income (before taxes)* This field is required.Income FAQs What income should I include? Include income from anyone you claim on your taxes and who will earn income in 2022. Include income from these sources: Federal taxable wages (from your job) Tips Self-employment income Unemployment income Social security Social security disability income (SSDI) Retirement or pension income Alimony (only if divorce or separation finalized before January 1st, 2019) Investment income Excluded (untaxed) foreign income Do not include income from these sources: Child support Gifts or loans Supplemental Security Income (SSI) Veterans' disability payments Worker's Compensation Whose income should be included? Include income from anyone who you claim on your taxes, such as your spouse or dependents. What if I’m married, but we file taxes separately? If you’re married and plan to file taxes "married filing separately" for the upcoming tax year, in most cases you won’t be eligible for savings. There are a few exceptions to this rule, such as cases of domestic violence or spousal abandonment. Please call us for more information. What if my income estimate is wrong? For right now, this is just an estimate, so that you can see an estimate of your savings—so a best guess is fine. When you actually apply for a plan, we’ll process your official income information and official savings. If your income changes throughout the year, you should update your application either online or by calling us. Why do you need my income? Your income is one of the factors that determines whether you’re eligible for Marketplace coverage or Medicaid. Also, whether you qualify for savings and the amount of savings you qualify for.

Do you have your AGI(Annual Gross Income) form last year's taxes?See line 37 from your 1040 Tax Form

Household Member #1* This field is required.You can apply for yourself or anyone who lives with you. PLEASE ENTER: Birthdate, Height, Weight, Gender, Tobacco Usage, Pregnancy Status

Household Member #2You can apply for yourself or anyone who lives with you. PLEASE ENTER: Birthdate, Height, Weight, Gender, Tobacco Usage, Pregnancy Status

Household Member #3You can apply for yourself or anyone who lives with you. PLEASE ENTER: Birthdate, Height, Weight, Gender, Tobacco Usage, Pregnancy Status

Household Member #4You can apply for yourself or anyone who lives with you. PLEASE ENTER: Birthdate, Height, Weight, Gender, Tobacco Usage, Pregnancy Status

Household Member #5You can apply for yourself or anyone who lives with you. PLEASE ENTER: Birthdate, Height, Weight, Gender, Tobacco Usage, Pregnancy Status

Household Member #6You can apply for yourself or anyone who lives with you. PLEASE ENTER: Birthdate, Height, Weight, Gender, Tobacco Usage, Pregnancy Status

Household Member #7You can apply for yourself or anyone who lives with you. PLEASE ENTER: Birthdate, Height, Weight, Gender, Tobacco Usage, Pregnancy Status

Household Member #8You can apply for yourself or anyone who lives with you. PLEASE ENTER: Birthdate, Height, Weight, Gender, Tobacco Usage, Pregnancy Status

Are your household members eligible for the any of following insurance?Please select all that apply.

Employer Coverage

Medicaid

CHIP

Medicare

Does your household have any preferred doctors, pharmacies, or hospitals?Please list their names and locations(if known).

Does your household take any prescription drugs?This may be helpful when choosing a plan! Please list by family member if possible.

Do you currently have health insurance?* This field is required.

YESNO

Who is your health insurance company?

How much do you pay?

Do you pay 100% of the payment for your current plan?

YESNO

If known, enter your deductible.

What is your Copay?

50/50

60/40

70/30

80/20

90/10

I'm not sure

Do you have coverage for the following:Please check all that apply.

Accidents

Critical Illness

Cancer

Dental

Vision

Hearing

Death(Life Insurance)

Disability(Paycheck Protection)

What do you like about your plan?

What do you NOT like about your plan?

How much do you spend monthly for prescription medicine?

How many times a year do you(or your household members) go to the doctor?

Has anyone in your household seen a doctor in the last 12 months?

YESNO

Has anyone in your household had any surgeries, cancers, heart attacks, strokes or major illnesses in the last 5 years?

YESNO

What is your preferred budget for coverage?* This field is required.Naming an amount or range will help me put together a plan that has the best value and comprehensive set of benefits. You are able to customize the plan to your budget and preferences.

Name* This field is required.

First Name

Last Name

Phone Number* This field is required.

Area Code

Phone Number

E-mail* This field is required.

What insurance plans would you like to review? Can be now or in the future!As an independent insurance broker my goal is to help you shop around while filling the gaps in your coverage. Please check all boxes that you know you need to review within the next year. I will send you the appropriate forms to get competitive quotes.

Life - Term and/or Lifetime, Burial, Child Plans

Disability - Individual, Protect Your Paycheck

Dental, Vision, Hearing - Can be individual or combined together

Hospital Indemnity Plans - Reimbursement for hospital stays, ambulance, emergency room

Critical Illness - Cancer, Heart Attack, Stroke, etc…

Personal Insurance - Home, Auto, Recreational Vehicles, Personal Items, Liability, etc...

Annuities - 401 Rollover, Retirement planning, Safe Money Accounts(Upside Potential w/o the downside risk)

Business Owners - Buy Sell Agreement, Key Employee Coverage, Employee Benefits - Life, Accident, Hospital, Cancer, etc…

Business Owners Disability - Business Overhead Expense Coverage, Key employee

Commercial Insurance - Workers Comp, Auto, General Liability, Cyber Liability, etc...

I consent to receive follow-up telephone calls and text messages from Insure The Heroes, Inc. regarding insurance quotes from telephone number: (305)373-3666.* This field is required.Your information will never be sold or provided to a third party. It is solely for the purpose of working with Insure The Heroes, Inc. Your information will be used for for insurance coverage at the time of your your application. Additional info will be requested.

YESNO

I understand this form submission is NOT an application for coverage and that coverage CANNOT be bound by this entry. This is for a quote ONLY.* This field is required.Please call Melissa Schreur directly if you are in need of immediate assistance (305)373-3666.

YESNO

Life - Term and/or Lifetime, Burial, Child Plans

Disability - Individual, Protect Your Paycheck

Dental, Vision, Hearing - Can be individual or combined together

Hospital Indemnity Plans - Reimbursement for hospital stays, ambulance, emergency room

Critical Illness - Cancer, Heart Attack, Stroke, etc…

Personal Insurance - Home, Auto, Recreational Vehicles, Personal Items, Liability, etc...

Annuities - 401 Rollover, Retirement planning, Safe Money Accounts(Upside Potential w/o the downside risk)

Business Owners - Buy Sell Agreement, Key Employee Coverage, Employee Benefits - Life, Accident, Hospital, Cancer, etc…

Business Owners Disability - Business Overhead Expense Coverage, Key employee

Commercial Insurance - Workers Comp, Auto, General Liability, Cyber Liability, etc...

Health Insurance Quote Request