Health Insurance Fact Finder

To get started with a Health Insurance Quote we would need some basic information. Below is a fact finder to get the ball rolling. Please do not put any Personal / Sensitive Information Below. By Filling out the Information Below You agree to an Insurance agent contacting you to discuss options. If this quote is time sensitive please call Robert at the office at (203) 510-5430.

Please complete the form below

****If you are age 65 or older please do not fill out information below, it would be best to call the office 203-510-5430 to discuss Senior Options.****

Number of People Requesting Coverage

What County Do You Live In?

What Town Do You Live In?

What Are the Dates Of Birth of Members Requesting Coverage?

Primary

YYYY

Spouse

YYYY

Dependent 1

YYYY

Dependent 2

YYYY

Dependent 3

YYYY

If More then 3 Dependants Please Add other Birthdays as MM/DD/YYYY (seperated by / or ,)

Do Any Household Members Smoke

Yes

Best Contact Phone Number

(###)

###

####

Best Email Address to Reach You

If Interested to see if you may Qualify for Subsidies through Access Health CT (Affordable Care Act) Please Answer the additional Questions Below.

What is Your Families Modified Adjusted Gross Income Projected for THIS CURRENT year.

Anyone In Your Household Pregnant

Yes

(Optional)Give a General Overview of what you are trying to accomplish and any additional pertinent information. Please Do not include any confidential or sensitive information in your message. If time sensitive please call the office at 203-510-5430