Individual Proposal Request Form
This service provides you with a no-obligation insurance quote from Benefit Awareness. We are a full service insurance brokerage serving your state.
By answering the questions below we will show you multiple (no-bias) insurance companies that you can choose from. Our service is no cost to you!
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.
Our plans come with a coach to support you throughout the enrollment process.
If you have questions you can call or text 414-301-2504 anytime.
www.flexiblehealthpans.com
* Required
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?
*
Choose
Yes
No, and if I ever did I have not smoked in over one year.
Current Medical Insurance Company
*
Your answer
How much do you pay per month for your plan?
Your answer
Did you get a premium tax credit last year?
Yes
No
I do not know what that is
Clear selection
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 household income (estimate 2021)?
*
Your answer
In the past year have you had medical expenses over $1000?
*
Choose
Yes
No
In 2019 and 2020, did you have medical expenses over $1000 in either of those years?
Choose
Yes
No
Please list the medications you currently are taking:
Your answer
Do you have income protection that replaces your income if you get hurt on or off the job?
Choose
Yes
No
Do you have AFLAC (or anything like it) to help pay for medical expenses?
Choose
No I do not
Maybe, I don't know
Yes - I Do
Submit
Never submit passwords through Google Forms.
This form was created inside of Benefit Awareness.
Report Abuse
Forms
