Individual Proposal Request Form
This service provides you with a no-obligation insurance quote from Benefit Awareness, we show multiple (no-bias) insurance companies for you to choose from. This service is no cost to you, if you decide to sign up with any of our programs we are compensated from our brokers and the insurance companies that you choose.

We can help you plan and budget for your:

Health Insurance Needs
Life Insurance Needs
Accident & Hospital Needs
Disability Insurance Needs
Short Term Medical Needs

Please fill out the below information to the best of your knowledge and one of our navigators will help you determine what type of coverage options are available for you.

We will show you options and costs from various A-Rated insurance companies. No bias.

Finally, if there are ways to lower your premiums through wellness, diet, exercise, or fitness we will identify the opportunities or those subsidies. We can even help you get started on saving money with an custom action - wellness plan that gets you results.

Our plans come with a coach, a strategy, and a local athletic facility to support you, and your goals, throughout the process.

Your Last Name *
Your answer
Your First Name *
Your answer
Email Address *
Your answer
What is your date of birth? *
Your answer
How many days a week do you workout? *
Your answer
What is your phone number?
Your answer
What is your zip code? *
Your answer
List Names and (Date of Birth) of all covered members *
Your answer
Do you smoke? *
Current Medical Insurance Company *
Captionless Image
Your answer
How much do you pay per month for your plan?
Your answer
Do you know what your deductible is? If so, what is it?
Your answer
Describe what you like and what you do not like about your current plan.
Your answer
Why are you shopping out this policy?
Your answer
What is your occupation?
Your answer
What is your average annual income?
Your answer
In the past year have you had medical expenses over $1000? *
In 2016 and 2017, did you have medical expenses over $1000 in either of those years?
Please list the medications you currently are taking:
Your answer
Do you have disability income protection that replaces your income if you can not go to work for an illness or injury?
How much life insurance do you have?
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