Health Insurance Quote Request Fill out the details below to receive a personalized health insurance quote. Contact Information First Name * Last Name * Email * (to send you the quote) Phone Number * (in case we have questions) Street Number and Name * City * State * Zip Code * I would like the option to speak with a licensed agent to go over all details. Basic Information Date you need coverage to start * Reason you need to start a new health insurance policy * Select a reason... Lost insurance through work Just turned 26 and am no longer able to be covered under my parents policy Got divorced and lost insurance Just moved to the area and need to start a policy in California Got married or entered in a domestic partnership Had a baby or adopted or started fostering a child Became a US citizen or national or permanent legal resident No longer eligible for Medi-Cal It is open enrollment (Nov 1 – Jan 31) and I'm shopping coverage How many people are in your household? * 1 Person 2 People 3 People 4 People 5 People 6 People 7 People 8+ People Age of the oldest person * + Add age of next person Check all that apply: I or a household member is pregnant I or a household member is blind or disabled None of these apply to me or anyone in my household Type of Health Insurance What is most important to you about your health insurance? * 1 2 3 4 5 Lower premium with higher cost for care Higher premium with lower cost for care How often do you (or anyone in your household) expect to get care over the next 12 months? * Select care level... Low Use – 1 visit and tests: preventive services Medium Use – 4-5 visits that include tests and treatment High Use – surgery or outpatient treatment, a number of doctor visits and tests Very High Use – a hospital stay, outpatient treatment, a number of doctor visits and tests Prescription Use * Select prescription usage... Low – 2-3 prescriptions during the year for brief illness Medium Use – 1-2 prescriptions each month High Use – 3 prescriptions each month, often higher cost drugs Very High Use – 4 or more prescriptions each month or high cost drugs Do you have a health insurance company preference? (Check all that apply, subject to availability in your area) Blue Shield of California Kaiser Permanente Health Net Anthem Blue Cross Molina Healthcare Chinese Community Health Plan (CCHP) L.A. Care Health Plan Sharp Health Plan Valley Health Plan Western Health Advantage Inland Empire Health Plan (IEHP) Upload a copy of your current health plan (Optional) Upload your current summary of benefits or plan details to help us match or improve your current coverage. Request Quote
