Agent Name Today's Date (required) Requested Effective Date (required) Need Quote By (required) Phone Number (required) Email (required) Zip Code (required) Name (required) Male / Female MaleFemale Date of Birth (required) Smoke / Chew YesNo Spouse Male / Female MaleFemale Date of Birth Smoke / Chew YesNo Number of Children to be Covered (required) Name Male / Female MaleFemale Date of Birth Name Male / Female MaleFemale Date of Birth Name Male / Female MaleFemale Date of Birth Name Male / Female MaleFemale Date of Birth Current Insurance Carrier Current Rate Current Deductible Quoting Questions: 1. Is the monthly premium or deductible/out-of-pocket maximum a bigger concern? 2. Do you want office visit copays? Prescription coverage? 3. If you live in or around Sioux Falls, do you prefer Avera or Sanford? 4. Is anyone offered coverage through their employer? If so, what is the Employee Only cost? South Dakota AveraSanfordShort Term (Not Available During Open Enrollment) Iowa MedicaWellmark (Only Available Through Exchange)Short Term (Not Available During Open Enrollment) North Dakota BCBSSanford Minnesota BCBS Nebraska Medica Deductible $1000$3000$5000HSA Ancillary DentalVisionAflacLegalShield (Identity Theft, Legal Services) Household Income (Needed to provide quotes for Exchange) Qualifying Event YesNo Reason: Date:
