Individual Quote Request Form (Under 65)
Thank you for choosing Skelton-Morris Associates to service your insurance needs. If you need a quote during open enrollment or for a special enrollment period, please complete the form below and an associate will be in touch with you soon.
Name of Applicant
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Address
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County In Which Applicant Resides
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Gender
Date of Birth
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DD
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YYYY
Tobacco Use?
Primary Care Physician or Specialist that you utilize? (Please list.)
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Preferred Pharmacy
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Medications (Please list.)
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Do you prefer to be contacted by email or phone with your proposal?
Email Address:
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Phone Number:
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Are you interested in a Federal Marketplace Plan? Subsidies are based on gross annual income.
If you are interested in a Federal Marketplace Plan, we will need more information from you. Please list your total household income (gross).
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Please list the number of persons living in your household.
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