Affordable Health Coverage

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Please allow us to help you by providing some basic information which will be held stricty confidential and not sold to any 3rd party:
*The field marked with () are required fields.**
*	First Name
*	Last Name
*	Email Address
	Address Line 1
	Address Line 2
*	City
*	State
*	Zip Code
	Country
*	Telephone Number
		Please share anything you'd like to inform me about your situation:

*		Are you currently insured?
		Yes No
		If Yes, do you get health coverage through your job or an individual plan? Or are you currently on COBRA?
		Employer Plan Individual Plan COBRA
*		Please indicate how people are to be covered

*		Does anyone to be covered have any history in the last 10 years of Heart problems, Diabetes, Cancer, Seizures, High Blood Pressure, High Cholesterol, Hospitalization for Mental Health or Substance Abuse or any other pre-existing condition or ongoing follow-up work (these won't all necessarily be a problem based on the carrier you choose to go with)?
		Yes No
		If Yes, please describe:

*		Are you currently pregnant or an expectant father?
		Yes No
*		Do you need maternity coverage?
		Yes No
*		When would you like your coverage to start?
		Immediately Next 30 days 1 month 2-6 months 6+ months
*		Do you only need coverage for the next 1-6 months?
		Yes No
*		I have plans for any budget so please let me know what range of affordability you fall into so we can head down the right road:
		Less than $100/mo $100-$200/mo $200-$300/mo $300-$400/mo $400-$600/mo $600+/mo.
*		Would you like Dental/Vision coverage?
		Yes No
*		Would you also like a life insurance quote?
		Yes No

Thanks!

Please feel free to contact me in various ways as listed below for more information.

Clint Thomas

Email: clint@affordablehealthcoverage.net

Telephone: (703)431-4087
Fax: (978)285-8790