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.
Your Last Name *
Your First Name *
Email Address *
What is your date of birth? *
How many days a week do you workout? *
What is your phone number?
What is your zip code? *
List Names and (Date of Birth) of all covered members *
Do you smoke? *
Current Medical Insurance Company *
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How much do you pay per month for your plan?
Did you get a premium tax credit last year?
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Do you know what your deductible is? If so, what is it?
Describe what you like and what you do not like about your current plan.
Why are you shopping out this policy?
What is your occupation?
What is your average annual household income (estimate 2021)? *
In the past year have you had medical expenses over $1000? *
In 2019 and 2020, did you have medical expenses over $1000 in either of those years?
Please list the medications you currently are taking:
Do you have income protection that replaces your income if you get hurt on or off the job?
Do you have AFLAC (or anything like it) to help pay for medical expenses?
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