Individual Health Quote Request

Contact Email*

Contact Name*

First Last

What can we help you with today?*

Please describe your current situation*

Please include plan name and all medications

Primary Applicant Information

Who are you looking for coverage for?*

Gender*

Male

Female

Preferred not listed

Prefer not to answer

Prefer to self describe gender as:*

Date of Birth

Tobacco User?

Yes

Applicant Address

Street Address Address Line 2 City State ZIP Code

Contact Phone Number*

Spouse Information

Name*

First Last

Date of Birth

Tobacco User?

Yes

Dependents

Dependent information*

Please press "+" button to the right to add additional dependents

Dependent First Name

Dependent Last Name

Dependent date of birth (MM/DD/YYYY)

Gender at birth

Special Enrollment

Event type

Date of Event or Loss of coverage

Other qualifying events include:

Changes in your income that affect the coverage you qualify for
Gaining membership in a federally recognized tribe of status as an Alaska Native Claims Settlement Act corporation shareholder
Becoming a U.S. citizen
Leaving incarceration
AmeriCorps member starting or ending service

Eligibility for Subsidies

Does your employer or your spouses employer offer health insurance?

Yes

Do you receive Medicare?

Yes

Household Annual Gross Income*

Income Source

Expected 2025 Annual Gross Income ($)

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For 2023, what is your projected Household Adjusted Gross Income?-dnu*

Would you be interested in Non-ACA plans (e.g. Short Term plans?)

They typically have a Lower Premium, health underwriting (no pre-existing conditions), and only provide catastrophic coverage.

Which UNICO Advisor are you currently working with?*

Karla Wilson

Nikki Bruns

None

Were you referred by someone?

If so, please enter their name

Confirm the Accuracy of Your Information*

I have reviewed all the information above and its accuracy to the best of my knowledge. I understand incorrect information provided may lead to increased processing time.

I have reviewed my information