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

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Quote Request Form

First Name

Last Name

Email Address

Home Address*

Address line 1

City

State

Zip Code

Today's Date*

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Insurance Needed*

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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*

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Tobacco Use*

Yes

No

Spouse

Name

Gender

M

F

Date of Birth

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Tobacco Use

Yes

No

Child

Name

Gender

M

F

Date of Birth

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Tobacco Use

Yes

No

Child

Name

Gender

M

F

Date of Birth

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Tobacco Use

Yes

No

Child

Name

Gender

M

F

Date of Birth

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Tobacco Use

Yes

No

Child

Name

Gender

M

F

Date of Birth

Select Date ×

Tobacco Use

Yes

No

Requested Date of Coverage*

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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

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Individual Health Solutions

1036 W. Juneau Avenue, Suite 302
Milwaukee, WI 53233

N63 W. 23231 Main St, Suite 201
Sussex, WI 53089

Contact Us | 414-615-1857

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