Health Insurance Quote We only require your first name, email address, the Arizona county you live in, your Zip Code and the age and gender of the family members 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*Do you want us to call you?* Yes No Zip Code* Unlike the ObamaCare plans, the much-less expensive non-ObamaCare plans are medically underwritten and you could be turned down due to certain pre-existing health conditions. During 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 In which county do you live?* Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma ApplicantDate of Birth* Month Day Year OPTIONAL: IF YOU WANT US TO TELL YOU WHAT YOUR POTENTIAL TAX CREDIT AMOUNT WOULD BE (THE AMOUNT THE GOVERNMENT WOULD PAY TOWARD YOUR PREMIUM EACH MONTH), TELL US WHAT YOU THINK YOUR ENTIRE HOUSEHOLD’S ANNUAL INCOME WILL BE AND THE NUMBER OF PEOPLE IN YOUR HOUSEHOLD: 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
