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What type of coverage are you seeking help in? (Check all that apply)
Affordable Health Insurance
Term Cashback Coverage
Whole Life Cash Value Coverage
Premium Return Mortgage Protection
Medicare benefits review
Final Expense Immediate Coverage
Immediate Dental/Vision Coverage
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Do you currently have health insurance?
Yes, I have employer coverage
Yes, I have private insurance
Yes, I have Medicaid
Yes, I have Medicare
No, I dont have any health insurance
Im not sure about my current coverage
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Have you previously lost or currently have medicaid?
I currently have medicaid
I recently lost medicaid
I don't have medicaid
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Have you had any significant life changes in the past year:
Lost health coverage (job, Medicaid, COBRA, aged off parent’s plan)
Household change (marriage, divorce, had/adopted a baby)
Income changed or employer coverage is no longer affordable
Turning 26 & no longer eligible for a parents plan.
Moved out of your current coverage area
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What is your annual household income?
Less than $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $60,000
$60,000 - $75,000
Over $75,000
I'm not sure.
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Do you currently have life insurance in place to cover final expenses or any outstanding debts?
Yes I have coverage in place
No, I don't have any coverage in place
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What is your current premium amount?
Providing an accurate amount helps us confirm eligibility for any available premium reductions.
Do you have any chronic health conditions or ongoing medical needs?
Yes, I have one or more chronic conditions (e.g., heart disease, Cancer, COPD, etc.).
No, I’m generally healthy and have no ongoing medical needs.
I’m not sure if my condition qualifies as chronic.
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Do you have Diabetes?
Yes, Type 1
Yes, Type 2
No, I do not have diabetes.
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Do you have questions about what types of benefits or help is available to you, based on your current health or financial situation?
Yes, I'm not sure what benefits i might qualify for.
Not at the moment
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