Individual Health Insurance Name Financial Rep Today's Date * Requested Effective Date * Need Quote By * Phone Number * E-mail Address * Zip Code * Name * Male / Female Male Female Date of Birth * Smoke / Chew Yes No Spouse Name Male / Female Male Female Date of Birth Smoke / Chew Yes No Number of Children to be Covered * Name Male / Female Male Female Date of Birth Name Male / Female Male Female Date of Birth Name Male / Female Male Female Date of Birth child 4 Name Male / Female Male Female 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? 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 Avera Sanford Short Term (Not Available During Open Enrollment) Iowa Medica Wellmark (Only Available Through Exchange) hort Term (Not Available During Open Enrollment) North Dakota BCBS Sanford Minnesota BCBS Nebraska Medica Deductible $1000 $3000 $5000 HSA Ancillary Dental Vision Aflac LegalShield (Identity Theft, Legal Services) Household Income (Needed to provide quotes for Exchange) Qualifying Event Yes No Reason: Date:
