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 HiddenDo 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 Anytime When do you need coverage to begin?* As soon as possible January 2023 February 2023 March 2023 or later Zip Code* County*ApacheCochiseCoconinoGilaGrahamGreenleeLa PazMaricopaMohaveNavajoPimaPinalSanta CruzYavapaiYumaDuring the last 5 years, have you received medical treatment for any of the following: COPD or emphysema, type 1 diabetes, cancer, multiple sclerosis, heart disorders, Crohn's disease, alcohol/drug abuse, or immune system disorders?* Yes No ApplicantDate 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?Select123456HiddenAdd SpouseSpouse InformationDate of Birth Month Day Year Gender Male Female Smoker?? No Yes Child 1Date of Birth Month Day Year Gender Male Female Child 2Date of Birth Month Day Year Gender Male Female Child 3Date of Birth Month Day Year Gender Male Female Child 4Date of Birth Month Day Year Gender Male Female Child 5Date of Birth Month Day Year Gender Male Female Child 6Date of Birth Month Day Year Gender Male Female HiddenSection: CommentsQuestions or Comments
