Health Insurance Needs Assessment
  Please take a moment to fill out this form so we can find the best health insurance options for you and your family. If you're enrolling multiple family members, please complete a form for each person. We're here to help every step of the way!  
Primary applicant's full name & date of birth:  *
Primary applicant's full address: *
Applicant's phone number and email address: *
Are you currently employed? *
Required
Current insurance: *
Required
Do you smoke, use tobacco or vape? *
Required
Are you currently pregnant or planning within the next year? *
Required
List any medical conditions and current medications. *
When do you need your new health insurance to start? *
Best time to contact: *
Required
I consent for LaPorte Benefits Group to contact me for insurance quotes and information. *
Required
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