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Our Promise To You:

We will use the information that you have provided here to help you find the quotes you seek regarding Health Insurance. We will not sell, rent or lease your name, email address, or phone number for any other purpose. The information that you provide will be held in the strictest confidence and not used for any other purpose.

Please note that you do NOT have to be self employed to take advantages of our major medical health insurance plans. Our plans are available to all residents of Georgia*
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  • Are you currently covered by a health insurance program?
  • Are you self-employed?    Yes     No
     
  • If yes, how many full time employees?
     
  • Do you want your Plan Design to include: 
     

Ages of persons to be insured:

  • Male:
    Date of birth (mm/dd/yy):    /  / 20  Tobacco User?
  • Female:
    Date of birth (mm/dd/yy):    /  / 20 Tobacco User?
  • Child 1:
    Age
  • Child 2:
    Age
  • Child 3:
    Age
  • Child 4:
    Age

 

  • Please list any Prescription Medications:

          

  • In your own words, please list any Pre-Existing Conditions:

          

  • We are the Authorized Representative for Guaranteed Issue Health Insurance for the Self-Employed. Have you ever been declined health insurance?  
     
  • Is anyone pregnant? 

 

  • Which statement(s) best describe your current needs?

      I need insurance immediately.

      I am comparing rates to my current policy.

      My current rates are too high.

      My current insurance has been canceled.

        I am starting a business and no longer have insurance from my employer.

      The benefits from my employer have been reduced or are too expensive.

Time is Money!  Help us both save time and money by letting us know the best time to contact you.

  I request a plan designer  to contact me at this specified day and time:

Please select your appointment: 

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  Click only once please.It may take a few seconds to process your request.

Thank you for taking the time to fill out this form. A professional plan designer will contact you at your specified time to assist you with your Georgia Health Insurance decision.

 

Access to Affordable Georgia Health Insurance Coverage for Self Employed Individuals and Small Business