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
County In Which Applicant Resides
Date of Birth
Primary Care Physician or Specialist that you utilize? (Please list.)
Medications (Please list.)
Do you prefer to be contacted by email or phone with your proposal?
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).
Please list the number of persons living in your household.
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