Health Insurance Enrollment Questionnaire

Thank you for your interest in Health Insurance Enrollment. Please take a few minutes to submit our online Health Insurance Enrollment Questionnaire so that we can adequately meet your health insurance needs.

First Name

Last Name

Date of Birth

Phone

Mailing Address

City

Dropdown

Zip Code

Number of Individuals in Household for Tax Purposes:

Number of Individuals to be Covered:

Taxable Income or Modified Adjusted Gross Income (MAGI):

Please List Name, Date of Birth, and Y/N for Tobacco Use

Individual 2:

Individual 3:

Individual 4:

Individual 5:

Please list any Doctors or Hospitals you feel are important:

If you would rather download the PDF Individual Health Insurance Information Sheet IOB, you can submit via:
Email to nmiklos@insureonebenefits.com
Mail: InsureOne Benefits
5000 Foote Road
Medina, OH 44256
Fax: 877-562-3133