Individual Stand Alone Form - Lehrman Group Health Insurance Brokers

Individual & Family
Get Employee Benefits
Get Medicare Rates
News
More

800 600 9663

Toll Free

Health Insurance Quote

Please enter your name, email address, your Arizona county, Zip Code and the age and gender of each family member you want to insure.

Name*
First Last
Hidden
Do you have a “special enrollment event” that will allow you to purchase an ObamaCare plan now that Open Enrollment is over? Some special enrollment events include losing group coverage in the last 60 days, moving to Arizona in the last 60 days, getting married and few more. If you say NO, we will send you information about PPO plans that are not subject to the open enrollment dates:
- Yes
- No
Email*
Enter Email Confirm Email
Phone*
What is the best time to call you:*
- Morning
- Afternoon
- Any time
When do you need coverage to begin?
- As soon as possible
- April 2025
- May 2025
- June 2025 or later
Zip Code*
County*
Apache
During the last 5 years, have you received medical treatment for any of the following: COPD or emphysema, diabetes, cancer, multiple sclerosis, heart disorders, Crohn's disease, alcohol/drug abuse, or immune system disorders? (If "no," we'll also send you non-Obamacare plan options that can give access to larger nationwide networks.)*
- Yes
- No
Open Enrollment is over, so you may not be able to get an Obamacare plan at this time. However, certain life events, like losing existing coverage, moving to a new area, or getting married/divorced, may qualify you to enroll in an Obamacare plan outside the Open Enrollment period. Do you qualify for a "Special Enrollment Period?" If you say NO, we'll only send you rates for non-Obamacare plans.*
- Yes
- No
- Not sure, please call me
Applicant
Date of Birth*
Month
Day
Year
Optional: You may qualify for a tax credit that substantially lowers your monthly premium. If you want us to calculate the tax credit, enter your annual household income and the number of people in your tax household (the number of people included on your tax return):
Gender*
- Male
- Female
Smoker??*
- No
- Yes
Who needs coverage?*
- Just myself
- Myself and my spouse
- Myself and my children
- Family
How many children are you seeking coverage for?
Select
Hidden
Add Spouse
Spouse Information
Date of Birth
Month
Day
Year
Gender
- Male
- Female
Smoker??
- No
- Yes
Child 1
Date of Birth
Month
Day
Year
Gender
- Male
- Female
Child 2
Date of Birth
Month
Day
Year
Gender
- Male
- Female
Child 3
Date of Birth
Month
Day
Year
Gender
- Male
- Female
Child 4
Date of Birth
Month
Day
Year
Gender
- Male
- Female
Child 5
Date of Birth
Month
Day
Year
Gender
- Male
- Female
Child 6
Date of Birth
Month
Day
Year
Gender
- Male
- Female
Hidden
Section: Comments
Questions or Comments

ABOUT

Established in 1988 by Tony Lehrman, LehrmanGroup is a leading provider of health insurance plans for Arizona residents and employers.

CONTACT INFO

Toll Free (800) 600-9663
Phoenix (623) 455-6997
Tucson (520) 760-0392

Mailing Address
PO Box 17690
Tucson 85731-7690

Phoenix Office
1910 S Stapley Drive #221
Mesa, Arizona 85204

Tucson Office
333 N. Wilmot Road, #340
Tucson Arizona 85711

QUICK LINKS

Home
Latest News
Individual & Family
Arizona Group Health Insurance Plans
Short Term Health Insurance
Medicare
Long Term Care

LATEST NEWS

Why is Lehrman Group the smart choice when buying a health insurance plan? September 24, 2024
The Smart Choice for Your Arizona Business’s Group Health Insurance Needs June 17, 2024

© 2025 Lehrman Financial Group Corporation. All Rights Reserved.

Notifications