Health Coverage Qualification Questionnaire

Completing this questionnaire gives me the information I need to research coverage options for you and your family before making recommendations. Most people can complete it in approximately 10–15 minutes.

Some questions may appear based on your answers. These additional questions help me identify plans that may be a good fit and avoid recommending options that may not work for your medical, prescription, or provider needs. Please answer as accurately as possible.

1 of 8

About You & Your Household

Let's start with your basic contact and household information.

This helps me show you the right number of family members in the next sections.

If uninsured, you can enter 'None'.

When would you like coverage to begin?

Household income may affect which coverage options or financial assistance are available to you.

Your Basic Information

Now let's gather some information about you.

Your Medical History & Medications

This information helps me identify plans that cover your ongoing medical needs.

Include diagnosis date if you can. Specific conditions will trigger additional questions.

This helps me ensure your medications are covered by the plans I research.

Your Surgeries & Hospitalizations

Tell us about any major medical events in the last 5 years.

This helps me research provider networks and ensure your preferred doctors are covered.

Additional Family Members

If others in your household need coverage, please provide their information. You can skip any sections that don't apply.

Family Member #2

Family Member #3

Family Member #4

Additional Coverage Needs

Beyond health insurance, are you interested in any of these additional coverage options?

What Matters Most to You?

When choosing health coverage, what are your top priorities? (Select up to 3)

Tip: Limiting your priorities helps me focus on plans that truly align with what matters most to you.

Almost Finished

I now have most of the information I need to begin researching your options. I may need a quick clarification before I complete my review.

What happens next: I'll review your household information, medical history, prescriptions, doctors, and coverage priorities and use it to research the options that may be appropriate for you. If I need clarification, I'll reach out using the contact information you provided. Once I've completed my review, I'll contact you with the appropriate next steps.