Insurance for One: Individual Insurance and Health Savings Accounts
Would you like health insurance your way? Choose your coverage. Choose your carrier
Get a Quote : Quote Request Form

Do you want more affordable health insurance? Looking for an affordable alternative to the insurance offered by your employer? Are you self-employed? In school? Between jobs? Don't get health insurance through your employer? Need dependent coverage?

Insurance for One™ may be just the coverage for you and your family. It's easy to get a free, no obligation quote—and a choice of carriers. Please provide some information below about your needs. We will identify the carriers (not just one or two) and coverage that fit your need and will help protect you and your family from the financial hardship of unexpected illness and injuries. We will contact you promptly if we need more information to provide you with the most accurate quotes.

We respect your privacy, and assure you that we will keep confidential any personal information as specified in our Privacy Policy.

Please complete the following:


(*required information)
First Name*
Middle Name
Last Name*
Date of Birth* (mm/dd/yyyy)
Gender*
Male Female
Address 1*
Address 2
City*
State*
Zip Code*
Email*
Phone*
Fax

Start of Coverage:


On what date should coverage begin?* (mm/dd/yyyy)

Preferred Contact Method:


Phone E-mail US Mail

When is the best time to contact you?


9 am–Noon 1–4 pm 4–7 pm

How did you hear about us?


Friend
Online Ad
Print Ad
Search Engine

Other

Family Members:


Please include only those family members for whom you want coverage. If you want coverage for dependent children only, enter the oldest child as the applicant.

    Gender Date of Birth (mm/dd/yyyy) Check if Tobacco User Check if Student
Applicant  
Male Female
Spouse  
Male Female
Child  
Male Female
Child  
Male Female
Child  
Male Female
Child  
Male Female
Child  
Male Female
Child  
Male Female

Type of Coverage:


Individual or Family Coverage
(health care coverage for more than 6 months)

Individual or Family Coverage - Short Term
(health care coverage for less than 6 months)

Please enter more details or your questions below:


Thank you for your request!

NOTICE: The use of the information you provide to us is governed by the Terms of Use and Privacy Policy posted to this website. By completing this form and clicking on the "Submit" button below, you acknowledge that you have read and accept the Terms of Use and Privacy Policy.


 


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