Individual Health Quote Request

List*

Child 1 Name	Child 1 DOB	Child 1 Gender

Special Enrollment
Event type
Date of Event or Loss of coverage
MM slash DD slash YYYY
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
- No
Do you receive Medicare?
- Yes
- No
For 2023, what is your projected Household Adjusted Gross Income?*
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
Were you referred by someone?
If so, please enter their name

Primary Applicant Information