Welcome to Unified Wellness!

This survey helps us understand your healthcare needs and find the best plan for you. It’s not an enrollment—just a way to see what plans you qualify for and get you a quote. After completing all the steps, you'll be able to review the plan that we recommend before making a decision. Let's get started.

When would you like your coverage to start? *

Each year rates change. This gives us an idea on what to recommend to you.

What type of health insurance are you looking for?

Free/Affordable Insurance

Gap/Critical Injury Policy(covers out of pocket expenses)

You can select one or more health insurance type

What are you prioritizing in your new healthcare coverage? *

Only $0 Plans

Plans under $100/Month

Best Coverage, Fair Price

Giving us an idea of what you’re looking for. This will not affect your price or what you can or cannot receive. It simply will help us prioritize our recommendations for you.

Tell us about your household

We use this information to ensure the rates are correct based on your age, tobacco usage, and geographic factors. We will protect this information as if it were our own.

***We comply with 45 CFR § 155.260 regarding the protection of your personally identifiable information. We strictly comply by HIPPA compliance and are licensed, insured & regulated by the Department of Insurance per licensed state.

First Name *

Middle Name

Last Name *

Date of birth

Gender

Male

Female

SSN

What is your physical address?

Street Address *

City *

Postal code *

State

Your location matters. To ensure we recommend the most suitable health insurance plans available in your area, please provide your address.

Who is in your household, and do they need coverage?

Include your spouse, any dependents on your taxes, and any adult children under age 26 that you want to cover by this plan. Rates are based on household size, and household income. Having members of your household added to the household size even if "not seeking coverage", will often lower your premiums.

Do You Have a Spouse?

Yes

Spouse's Full Name *

Spouse Birthdate *

Spouse Gender *

Spouse's SSN *

Add dependent/child?

Yes

Dependent Full Name *

Dependent Birthdate *

Dependent Gender *

Dependent SSN *

Dependent Full Name *

Dependent Birthdate *

Dependent Gender *

Dependent SSN *

Dependent Full Name *

Dependant Birthdate *

Dependant Gender *

Dependent SSN *

Dependent Full Name *

Dependant Birthdate *

Dependent Gender *

Dependent SSN *

Tell us about your healthcare needs

List any of your existing medications. Your answer will ensure our recommendations meet your needs.

List any needed prescription medication (Optional)

Primary Care Doctor's Full Name (Optional)

Tell us about your income

Accurately estimating your income for health insurance applications is crucial. It helps you get the right coverage and ensures that your premium tax credits are calculated correctly. This means more affordable and accessible health insurance for you and your family.

PS. You're almost done!

What is your estimated personal annual income for 2025?(Before Taxes)

What is your estimated business income for 2025?(Before Taxes)

Phone *

Email *

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