Health Insurance Questionnaire Health Insurance Questionnaire "*" indicates required fields Step 1 of 7 14% Who should we thank for sending you our way?Do you have coverage offered through an employer?* Yes No Will you soon or have you lost coverage in the past 60 days?* Yes No Last day of coverage* MM slash DD slash YYYY Name* First Last Email* Phone*Zip Code*Your Age*Gender* Male Female Who's in your household?* Just You You and other people Are you Married?* Yes No Spouse's Age*Spouse's Gender* Male Female On your 2026 federal tax return how many dependents are you claiming?*Include anyone who you'll claim as a tax dependent in 2025. Include them even if they don't need health coverage. Don't count yourself or your spouse as a dependent. None 1 2 3 4 5 6 Dependent 1 Age*Dependent 1 Gender* Male Female Dependent 2 Age*Dependent 2 Gender* Male Female Dependent 3 Age*Dependent 3 Gender* Male Female Dependent 4 Age*Dependent 4 Gender* Male Female Dependent 5 Age*Dependent 5 Gender* Male Female Dependent 6 Age*Dependent 6 Gender* Male Female What do you think your household adjusted gross income will be in 2025?*Income is counted for you, you spouse, and everyone you'll claim as a tax dependent (making more than $14k) on your federal tax return. Include their income even if they don't need health coverage.What do you think your household adjusted gross income will be in 2026?*Income is counted for you, you spouse, and everyone you'll claim as a tax dependent (making more than $14k) on your federal tax return. Include their income even if they don't need health coverage. Please List your doctors, prescriptions, or medical concerns we should consider when sending quotes.Do you know anyone else that needs help with their health insurance coverage? We would love to help!
