Self Employed Insurance Quote

Self Employed Health Insurance Short Form -
Estimated time to complete: 90 Seconds

We specialize in the needs of the Self Employed

We are different. Our association health plans are affordable and all plans are comprehensive major medical and catastrophic plans. Our professional plan designers are knowledgeable in helping you design a custom plan that's right for you your family and your business . Your help is required to insure none of your valuable time is wasted! We also employ an office staff of non-commissioned licensed professionals to assist you with any questions you might have. It will be beneficial to you to complete the following questionnaire. REMEMBER.....your inquiry is not being sold to a broker. The call you receive will be from a Self Employed Insurance Group plan designer who will identify themselves in that manner.

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	A.S.A.P. Questionnaire
I request a plan	designer to contact me at this specified day and time:.
Please select your appointment:	Day: required Best Time: required
	I understand that I will be available so the plan designer can assist me without interruption.

First Name	* required
Last Name	*required
City
State
Zip Code	*required
Work Phone	*required
Home Phone	*required
E-mail	*required

	Are you currently covered by a health insurance program?
	Are you self-employed? Yes No
	If yes, how many full time employees?
	Do you want your Plan Design to include:

Ages of persons to be insured:

Male:

Date of birth (dd/mm/yy):	/ /
Tobacco User?

Female:

Date of birth (dd/mm/yy):	/ /
Tobacco User?

Child 1:

Age

Child 2:

Age

Child 3:

Age

Child 4:

Age

Please list any Prescription Medications:

In your own words, please list any Pre-Existing Conditions:

None

	We are the Authorized Representative for Guaranteed Issue Health Insurance for the Self-Employed. Have you ever been declined health insurance?
	Is anyone pregnant?

Which statement(s) best describe your current needs?

I need insurance immediately.

I am comparing rates to my current policy.

My current rates are too high.

My current insurance has been canceled.

I am starting a business and no longer have insurance from my employer.

The benefits from my employer have been reduced or are too expensive.

It may take a few seconds to process your request.

Access to Affordable Health Insurance Coverage for Self Employed Individuals and Small Business