Type of Coverage required
-
Individual
Individual + Spouse
Individual + Family
Individual + Domestic Partner
Policy Holders First Name required
Middle Name
Last Name required
Gender required Male Female
Address required
City required
State required
Florida
Zip Code required
County required
-
Alachua
Baker
Bay
Bradford
Brevard
Broward
Calhoun
Charlotte
Citrus
Clay
Collier
Columbia
DeSoto
Dixie
Duval
Escambia
Flagler
Franklin
Gadsden
Gilchrist
Glades
Gulf
Hamilton
Hardee
Hendry
Hernando
Highlands
Hillsborough
Holmes
Indian River
Jackson
Jefferson
Lafayette
Lake
Lee
Leon
Levy
Liberty
Madison
Manatee
Marion
Martin
Miami-Dade
Monroe
Nassau
Okaloosa
Okeechobee
Orange
Osceola
Palm Beach
Pasco
Pinellas
Polk
Putnam
Santa Rosa
Sarasota
Seminole
St. Johns
St. Lucie
Sumter
Suwannee
Taylor
Union
Volusia
Wakulla
Walton
Washington
Email Address required
Smoker required Never Within the last 6 months Between 7-12 months ago Between 13-36 months ago More than 36 months ago
Client Status required Existing Client New Client
How did you hear about us?
Do you currently have health insurance? required Yes No
If yes, what type of policy? Individual / Family Group / Employer Plan COBRA
Optional Additional Coverages required Health Savings Account (HSA) Dental Insurance Vision Insurance Supplemental - Accident Supplemental - Cancer Supplemental - Hospital None
Current Doctors & Zip Code required
Please provide the names of your doctors and their location zip code so we can check their network participations.
Prescription Drugs, Dosage & Frequency required
Please provide the names of any prescription drugs, the dosage and how frequently you take them.
Household Size
Projected household Annual Income