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All fields are required. Review the information carefully and avoid mistakes.

Name

Last Name

Phone

State

City

Address

Zip Code

Birthdate

Gender

Do you or anyone who would be on your plan have any health insurance coverage in primary? Like Medicare/Medicaid, Obama care, depending on social security or disability plan? ( Must be NO )

If you like to buy the plan then the licensed agent will require electronic way of payment like Debit Card / Credit Card or Checking Account. Do you have a valid payment option available? (Must be YES)

Do you or anyone who would be on your plan have any kind of preexisting health conditions? Like cancer, HIV/aids, diabetes ( Must be NO )

Can you afford $200 for single or $400 for Family Health Insurance Plan (Must be YES)

If you like the plan and pricing and very much satisfied with the benefits of how soon you are planning to buy it?

What kind of plan you are looking for? Individual or family plan?

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