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Individual Health Quote Request

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Contact Name*
Please include plan name and all medications

Primary Applicant Information

Gender*
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Tobacco User?
Applicant Address

Spouse Information

Name*
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Tobacco User?

Dependents

Dependent information*
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Dependent First Name
Dependent Last Name
Dependent date of birth (MM/DD/YYYY)
Gender at birth
 

Special Enrollment

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?
Do you receive Medicare?
Household Annual Gross Income*
Income Source
Expected 2025 Annual Gross Income ($)
 
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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?*
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.

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Locations

1128 Lincoln Mall, Suite 200
Lincoln, NE 68508

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12120 Port Grace Blvd, Suite 102
La Vista, NE 68128

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2457 33rd Avenue
Columbus, NE 68601

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1317 W Pasewalk Ave #200
Norfolk, NE 68701

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