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GET QUOTES from leading insurers for HSA-qualified high deductible health plans
(It takes only about 3 minutes to complete this form. Then you can compare your options at your leisure.)
Coverage Information
Gender
Date of Birth
Height
Weight
Tobacco use?
(last 12 mos.)
Applicant
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M
F
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Ft
3
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In
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Spouse
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M
F
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7
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Child 1
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M
F
Please select your gender.
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Ft
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Child 2
--
M
F
Please select your gender.
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Ft
1
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5
6
In
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Child 3
--
M
F
Please select your gender.
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Ft
1
2
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4
5
6
In
0
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Child 4
--
M
F
Please select your gender.
/
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Ft
1
2
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4
5
6
In
0
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7
8
9
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Child 5
--
M
F
Please select your gender.
/
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Ft
1
2
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5
6
In
0
1
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Health Information
When would you like coverage to start?
-please select-
ASAP
within 15 days
within 30 days
within 45 days
over 45 days
No timetable
Are you currently insured?
yes
no
If yes, what is the name of your current insurance company?
--
Aetna
Assurant Health
Blue Cross
Blue Shield
Celtic Insurance Company
CIGNA
Golden Rule Insurance
Group Health Cooperative
Group Health Incorporated (GHI)
Health Net
HealthPartners
Humana
Intermountain Health Care (IHC)
Kaiser Permanente
LifeWise Health Plan
Medica
Medical Mutual of Ohio
Midwest Security
Oxford Health Plans
PacifiCare
Tufts Health Plan
UNICARE
United HealthCare
United Wisconsin Life/AMS
Vista Health Plan
Other
Has anyone taken any Rx medications in the past 12 months?
yes
no
Please provide info, including diagnosed name of condition(s):
Are there
any
pre-existing health conditions, current pregnancies, or scheduled diagnostic tests that have not been completed?
yes
no
Please use the box below to provide relevant details, including diagnosis, prognosis, etc.:
Some conditions are
uninsurable
including: diabetes; drug addiction, etc.
For details,
please click here to review a more in-depth list
(new browser opens)
Contact Information
First Name
(primary applicant)
Last Name
(primary applicant)
Address
(primary residence)
City
State
--Select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maryland
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
West Virginia
Wisconsin
Wyoming
Zip
Best Contact Phone
(required, please)
-
-
Alternate Phone
(also required)
-
-
Best contact time
Anytime
Morning
Afternoon
Evening
Email
(please double-check)
Name of person completing form
Relationship to Primary Applicant?
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