Health Insurance Enrollment
Contact
Are You Currently Insured?
Are You Currently Insured?
*
Yes
No
Do you have any pre-existing conditions?
Untitled
*
Yes
No
*Does not disqualify from all health insurance options.
Individual or Family Insurance?
Individual or Family Insurance?
*
Individual
Family
Male or Female?
Male or Female?
*
Male
Female
Date of Birth
Date of Birth
*
MM
DD
YYYY
What is your household income?
What is your household income?
*
Over $46,001
$30,001 - $46,000
$15,001 - $30,000
Under $15,000
Do any of these apply in the last 60 days?
What is your household income?
*
Married Or Divorced
Had Baby
Family Member Died
Moved To Another State
Lost My Job
Started New Job
Lost Health Insurance Coverage
None
Smoker or Non-Smoker?
Smoker or Non-Smoker?
*
Smoker
Non-smoker
Do you need prescription coverage?
Non-smokers qualify for lower rates
Do you need prescription coverage?
*
Yes
No
Please Complete the Fields Below
You may qualify for free prescriptions
First Name
*
Last Name
*
Phone Number
*
(will be verified by SMS)
Email Address
*
Google Address Selection
You must use a validated Google address.
Confirmed Google Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Street Address
Comments
This field is for validation purposes and should be left unchanged.
Name
This field is for validation purposes and should be left unchanged.
We’re a health insurance brokerage with agents licensed in states across the country. We will provide you free, no-obligation quotes and we can process your enrollment over the phone. Our licensed agents work with you directly and have a full customer service support team for questions
pre
and
post
enrollment. By executing these agreements, you further authorize Health Insurance Alliance, LLC. and its
partners or affiliates
, to contact you via automatic telephone dialing systems or by artificial or pre-recorded message, and you acknowledge that you understand that you are not required to enter into these agreements as a condition of purchasing any property, goods, or services.
Questions? Speak with a Licensed Agent
Partners & Affiliates
Accu Health Insurance
Alpine Digital Group, Inc.
America’s Health Advisors
America’s Health Center
America’s Health Providers
Precision Insurance Providers
Precision Healthcare
Health Insurance Alliance, LLC
Excel Impact
MediaAlpha
Quote Storm Holding
Contactability
Safeguard Insurance Market
Torchlight Technology
Number One Health
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Prefer to Call? Our Open Enrollment Center is on Call!
Licensed Health Insurance Agents available 7am - 10pm EST. No Wait!