Skip to content

Call 414-615-1857

REQUEST A QUOTE

Home
About
Services
Carriers
Request A Quote
News & Events
Contact

Request a Quote

Please complete all sections below. Your quote will be sent via email.

Click here for a print/email form. Email to ken@ihswi.com or fax: 414-271-3334.

Javascript is disabled

Javascript is disabled on your browser. Please enable it in order to use this form.

Loading

Quote Request Form

First Name

Last Name

Email Address

Home Address*

Address line 1

City

State

Zip Code

Today's Date*

Select Date ×

Insurance Needed*

Check any that apply

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

Medicare Plans

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

Travel Insurance

Required Information to Quote (Note: If you have more than 4 children, provide additional information in the 'Comments' field below.)

Primary

Name

Gender*

M

F

Date of Birth*

Select Date ×

Tobacco Use*

Yes

No

Spouse

Name

Gender

M

F

Date of Birth

Select Date ×

Tobacco Use

Yes

No

Child

Name

Gender

M

F

Date of Birth

Select Date ×

Tobacco Use

Yes

No

Child

Name

Gender

M

F

Date of Birth

Select Date ×

Tobacco Use

Yes

No

Child

Name

Gender

M

F

Date of Birth

Select Date ×

Tobacco Use

Yes

No

Child

Name

Gender

M

F

Date of Birth

Select Date ×

Tobacco Use

Yes

No

Requested Date of Coverage*

Select Date ×

Household Income*

Income

Health Insurance Questions

Do you currently have Health Insurance*

Yes

No

Name of Insurance Company*

Name of Insurance Company

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

Yes

No

Employer Name(s)*

Name(s) of Employer(s)

Preferred Doctors, Hospitals, etc.

Preferred Doctors, Hospitals, etc.

Family Size (to determine your subsidy eligibility)*

Family Size

Comments/Requests

1 plus 10 equals?*

Prove you are a human

Write here

Your quote request has been submitted

Thank you for your quote request. We will follow up with you shortly. In the meantime, if you have any immediate questions, please feel free to give us a call at 414-615-1857.

Server Side Error

We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again.

If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information.

TextStatus: undefined
HTTP Error: undefined

Processing your request

Error

Some error has occured.

Individual Health Solutions

100 E Wisconsin Ave. Suite 1500
Milwaukee, WI 53202

Contact Us | 414-615-1857

Stay Informed! Join our email list for useful insurance updates.

Leave this field empty if you're human:

© 2019 Individual Health Solutions | Website by LimeGlow Design