Health Insurance Landing Application

The Fast and Easy Way

Find the Right Plan:

Click on the "Details" link in each quote to see the plan features. Use the tabs at the top in "Customize Search" to focus on your preferences.
All insurers, all plans
If the list is too long, use Customize Search to narrow the selection using the drop down boxes
A particular insurance company
Select the insurance company under Customize Search in the Carrier tab

Tax deduction for out-of-pocket expenses
From the first dollar, what you pay in medical expenses before the deductible is met can be tax-deductible using contributions to a Health Savings Account (HSA)
Copays for doctor visits and prescriptions
If the HSA tax deduction is not important, these plans with various copays may be preferred (tax law does not allow both)
'Catastrophic' coverage
The lowest premiums possible, with or without tax deductibility for out-of-pocket expenses

These states are quoted separately: New Jersey New York Washington

Maine, Massachusetts, Rhode Island, and Vermont are not available here.

Start your application for any plan:

All information is encrypted. If you prefer to apply by mail, contact the insurance licensee:
• Insurance Licensee • Insurance Notice • Insurance Privacy Notice

Insurance Company that you are applying to:

Application FAQS Reasons for Being Declined

Name of Plan that you are applying for:

Deductible:

Coinsurance:

Monthly:

Effective Date:

Preferred Payment Method:

Your e-mail address:

Repeat e-mail address:

First Name:

Your Last Name:

Address – Street:

City:

State:

Zip:

Work/Day Phone:

Cell Phone:

Home Phone:

Primary Applicant:HeightWeightTobacco Last UseDriversSocial
M/FDate of Birth:ft - in:lbs:Date & Type: License# State: Security#

Date (approximate) of last visit to a doctor, chiropractor, or therapist:

Reason for visit:

Any weight gain in the last year and reason:

Name, address, and phone number of practitioner:

Tests done, findings, remaining effects:

Any weight loss in the last year and reason:

Spouse Applicant:

Name: HeightWeightTobacco Last UseDriversSocial
M/FDate of Birth:ft - in:lbs:Date & Type: License# State: Security#

Date (approximate) of last visit to a doctor, chiropractor, or therapist:

Reason for visit:

Amount of weight gain in the last year and reason:

Name, address, and phone number of practitioner:

Tests done, findings, remaining effects:

Amount of weight loss in the last year and reason:

Children from youngest to oldest:

Name: HeightWeight Tobacco Last UseDriversSocial
M/FDate of Birth:ft - in:lbs:Date & Type: License# State: Security#

Name: HeightWeight Tobacco Last UseDriversSocial
M/FDate of Birth:ft - in:lbs:Date & Type: License# State: Security#

Name: HeightWeight Tobacco Last UseDriversSocial
M/FDate of Birth:ft - in:lbs:Date & Type: License# State: Security#

Additional Children:

1. For everyone in this application: Yes No

a. if a family member is not approved, should approved members be enrolled?

b. were you previously covered by the insurer you are now applying to?

c. have you been covered by other health insurance in the last 90 days?

d. person(s) covered, name, address of insurer:

e. Type of coverage:

Provide details to any "yes" answers below in the "Details" section following.

In the last 10 years has anyone in this application had any indication, diagnosis, or treatment for:

q. Does anyone in this application have any mental or physical impairment, handicap, retardation, disease, or deformity or been examined or treated by any medical practitioner for any reason than disclosed above?

Details for all "yes" answers.
List these items: Question #, applicant's name; start and end date of treatment (ongoing/none); prescriptions and dosage, name of condition; remaining effects (or none) and % of recovery; name, address, and telephone number of physician, chiropractor, or therapist, and hospital.

4. Female Applicants - in the last 10 years:

a. Date of last pap smear and results/follow-up:

b. if more than 40 days since the last menstrual period, explain reason:

c. Name, address, and phone number of physician:

d. Have you had any abnormal pap smear results?:

Yes No

e. abnormal pap results: who, date, condition, if ended, % recovery, & date of last normal result:

5. a. Other than as stated above, has any applicant taken any prescription, alternative, complementary, herbal, or natural medications in the last 3 years? Yes No

b. Within the past year, has any applicant taken any supplements or over-the-counter medications for longer than 5 consecutive days? Yes No

c. If yes to either question, please state question #, applicant name, name of medication, dosage and frequency of medication, condition treated, date last taken, name and address of physician.

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