Request a Quote

Please complete all sections below. Your quote will be sent via email. If you’re looking to request a Medicare review, please click here.

Click here for a print/email form. Email to ken@ihswi.com.

Quote Request Form

General Information

First Name

Last Name

Phone

Address

City

County

State

Zip Code

Today's Date

Insurance Needed (Check all that apply)

Individual/Family Health Insurance (Marketplace & non-marketplace)

Medicare Plans

Vision Insurance

Travel Insurance

Dental Insurance

Required Information to Quote

Children

Name	Gender	Date of Birth	Tobacco Use

Requested Date of Coverage

Health Insurance Questions

Do you currently have Health Insurance?

Yes

Name of Insurance Company

What was the last day you had credible health insurance?

Do you an/or spouse have Health Insurance available through an employer?

Yes

Employer Name

Preferred doctors, hospitals, etc.

Annual household income and family size to determine your subsidy eligibility

Does anyone who will be included in the quote have access to a HRA — Health Reimbursement Account for premiums and out of pocket expenses?

Yes

Comments/Requests

I authorize Individual Health Solutions to assist me with reviewing options and potentially obtaining health insurance through the Federal Marketplace (healthcare.gov). I understand this grants permission to this broker to make changes to my healthcare.gov application on my behalf and at my direction. Permission can be rescinded at any time by submitting a request to my agent in writing. Permission will be rescinded on the date of the request.

Request a Quote

General Information

Required Information to Quote

Primary

Spouse

Children

Health Insurance Questions

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