FREE HEALTH QUOTE Health Quote Healthcare "*" indicates required fields 1How can we help?2Getting to know you?3Additional Information Please select the insurance we can help you with:* Health (18-64) Medicare (65+ or exceptions) Dental Vision Life Disability Long Term Care Name* First Last What is your Date of Birth* MM slash DD slash YYYY Phone*Email Physical Address*This is the address where you live. Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your mailing address the same as your physical address* Yes No Mailing AddressThis is the address where you receive mail Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender (at birth)* Male Female Are you married or have a partner?* Yes No Tobacco Usage:*NoneCigarettesCigarsChewNicotine ReplacementVape/E-cigaretteOther/unknownIf quit, date last used:* MM slash DD slash YYYY HealthGross Annual Household Income: How many other people live in your household (excluding yourself)*012345678 or morePerson 1's Name* First Last Person 1's Date of Birth* MM slash DD slash YYYY What is Person 1's gender at birth?* Male Female Has Person 1 used any form of nicotine in the past 6 months?* Yes No Tobacco Usage:*NoneCigarettesCigarsChewNicotine ReplacementVape/E-cigaretteOther/unknownPerson 2's Name* First Last Person 2's Date of Birth* MM slash DD slash YYYY What is Person 2's gender at birth?* Male Female Has Person 2 used any form of nicotine in the past 6 months?* Yes No Tobacco Usage:NoneCigarettesCigarsChewNicotine ReplacementVape/E-cigaretteOther/unknownPerson 3's Name* First Last Person 3's Date of Birth* MM slash DD slash YYYY What is Person 3's gender at birth?* Male Female Has Person 3 used any form of nicotine in the past 6 months?* Yes No Tobacco Usage:NoneCigarettesCigarsChewNicotine ReplacementVape/E-cigaretteOther/unknownPerson 4's Name* First Last Person 4's Date of Birth* MM slash DD slash YYYY What is Person 4's gender at birth?* Male Female Has Person 4 used any form of nicotine in the past 6 months?* Yes No Tobacco Usage:NoneCigarettesCigarsChewNicotine ReplacementVape/E-cigaretteOther/unknownPerson 5's Name* First Last Person 5's Date of Birth* MM slash DD slash YYYY What is Person 5's gender at birth?* Male Female Has Person 5 used any form of nicotine in the past 6 months?* Yes No Tobacco Usage:NoneCigarettesCigarsChewNicotine ReplacementVape/E-cigaretteOther/unknownPerson 6's Name* First Last Person 6's Date of Birth* MM slash DD slash YYYY What is Person 6's gender at birth?* Male Female Has Person 6 used any form of nicotine in the past 6 months?* Yes No Tobacco Usage:NoneCigarettesCigarsChewNicotine ReplacementVape/E-cigaretteOther/unknownPerson 7's Name* First Last Person 7's Date of Birth* MM slash DD slash YYYY What is Person 7's gender at birth?* Male Female Has Person 7 used any form of nicotine in the past 6 months?* Yes No Tobacco Usage:*NoneCigarettesCigarsChewNicotine ReplacementVape/E-cigaretteOther/unknownPerson 8's and any other residents information*MedicareAre you currently enrolled in Medicaid?* Yes No The state program providing additional assistance for low-income residents.What qualifies you for Medicare?* Already in (65 or older) Aging Into (turning 65) Disability or Medical Condition Anticipated Part A effective date:* MM slash DD slash YYYY Anticipated Part B effective date:* MM slash DD slash YYYY Part A effective date (if available):* MM slash DD slash YYYY Part B effective date (if available):* MM slash DD slash YYYY Please describe your disability or medical condition:*Please list any providers you wish to continue to work with (doctors/hospitals):*Please list any current medications, including dosage and frequency:*LifeWhat insurance carrier do you currently have (if any)? What is your height and weight? Height Weight Have you used nicotine in the past five years?* Yes No Tobacco Usage:*NoneCigarettesCigarsChewNicotine ReplacementVape/E-cigaretteOther/unknownDo you, a parent, or a sibling have a history of the following:* Cancer Diabetes Heart Disease Respiratory Disease None of the above Please list any current medications (including dosage, frequency, and reason for prescription)*DisabilityWhat type of Disability quote are you requesting?* Personal Disability Insurance Retirement Protection Loan Indemnification Annual income of the individual seeking coverage:* Occupation* Position Duties:*Business Owner?* No Yes Company Name:* Loan IndemnificationMonthly Payment Amount* Principal Loan Amount* Term of Loan* Is there any existing coverage?* Yes No Personal Disability InsuranceDo you have existing Individual Disability Benefit?* Yes No Amount:* Retirement ProtectionDo you have existing Retirement Protection?* Yes No Amount:* Dental/VisionRequested Effective Date: MM slash DD slash YYYY Please list any specific procedure(s) needing coverage:Please list any preferred Dentists: Long Term CareACCURATE Height and WeightBased off of most recent Doctors appointment Height Weight Date of most recent doctors visit MM slash DD slash YYYY Please list ALL current medications and reason for use:Any recorded history of anxiety? Yes No Use assistive devices (cane, walker) even occasionally? Yes No Any recorded history of substance abuse? Yes No Currently receiving any disability income? Yes No What type and what percentage of income? Type % Any previous surgeries or hospitalizations? Yes No Type of visit(s), reason for visit(s), and when did the visit(s) occur?Two or more immediate family members with Alzheimer's or Dementia? Yes No Have you been diagnosed with Parkinson's? Yes No Have you been diagnosed with Multiple Sclerosis? Yes No Any history of stroke or TIA? Yes No When and how many?Been Previously declined for LTC or Life Insurance? Yes No Which one, when and why?Diabetes? Yes No What type, when were you diagnosed, last A1C count, any insulin use even if occasionally?Depression? Yes No Diagnosis date or onset date, any psychiatric work, hospitalizations, or shock therapyCancer? Yes No What stage, location, type of treatment, last treatment date, positive lymph node count, any recurrences?Heart Attack or Heart Disease? Yes No Indicate if heart attack - how many and when, bypass or stets, if stents - how many and when, any angioplasty, congestive heart failure, circulatory disease, etc?Arthritis? Yes No Indicate what type, which joints are affected, any limitations, steroid use?Dizziness? Yes No Indicate the cause, when it started, any falls, what type of treatment?Blood Clots? Yes No Indicate the cause, single or multiple clots, the treatment needed, respiratory or circulatory disorders, any limitations?COPD, Osteoporosis, or unlisted disorder? Yes No Indicate diagnosis date, use of a nebulizer and how much, any use of oxygen, current T-scores, spinal compression or bone fractures, falls, etc?Consent*By checking this box, you allow us to contact you regarding our services and products. Any information provided will be used for internal use only. I understand that Benefit Solutions Plus, LLC is bound under regulations to keep all personal information private, and will not sell personal information to any third party company. I agreeEmailThis field is for validation purposes and should be left unchanged. Δ