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Health
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ACA (ObamaCare) Quote Form
ACA (ObamaCare) Quote Form
Open enrollment for ObamaCare, also commonly known as the Affordable Care Act (ACA),
is November 15, 2014 through February 15, 2015.
Neighborhood Insurance Services, Inc.
will help you understand the ACA process, the costs, and the benefits, so you can make an informed health insurance purchase. We will guide you through the process and help you apply for ACA health insurance during the open enrollment period.
We work hard to find the most affordable coverage available for any situation or need, including pre-existing conditions.
C
omplete the form below and b
egin the process with a free, no obligation quote.
A
Neighborhood Insurance Services, Inc.
professional will contact you to discuss your benefits and premiums options. Be sure to complete ALL applicable fields.
Submit your form before November 16, 2014 and you will be entered for a chance to win a $200 VISA gift card. Earn extra chances by referring family and friends. Receive one (1) entry for each referral (1 per household) who submits a quote form and receives a free quote.
Click Here to Download Promotion Flyer
and share with your family and friends or
Click here to refer your family and friends online.
You must request a free quote to receive an entry. However, NO purchase is required to participate or to win.
ACA (ObamaCare) coverage is ONLY for HEALTH INSURANCE. If you are also interested in the following insurances, please check ALL that apply.
Optional
Dental
Vision
Life
Accident
Cancer
Primary Applicant
First Name
Required
Last Name
Required
SEX
Required
Male
Female
Do you or have you used tobacco products?
Required
Yes
No
SSN
Required
Street
Required
City
Required
State
Required
AL
AR
FL
GA
LA
MS
TN
TX
ZIP / Postal Code
Required
What County do you live in?
Required
Primary Phone Number
Required
E-Mail Address
Required
Your Date of Birth
Required
Spouse's Date of Birth
Optional
Your Place of Employment
Optional
Work Phone (Primary)
Optional
Spouse's Place of Employment
Optional
Work Phone Spouse
Optional
Is Employer Health Insurance Offered?
Optional
Yes
No
Hold down the Ctrl Key to make multiple selections.
Your Total Modified Yearly Gross Income
Required
Spouse Total Modified Yearly Gross Income
Optional
Dependent's Total Modified Yearly Gross Income
Optional
Do you plan to file taxes next year?
Required
Yes
No
How do you plan to file taxes?
Required
Single
Married
Head of Household
Married Filing Single
Dependents that need insurance (Claimed on taxes)
Name of Dependent #1
Optional
Dependent # 1 - Date of Birth
Optional
Dependent #1 SSN
Optional
Dependent # 1 Sex - Indicate Male or Female
Optional
Does Dependent #1 use tobacco products?- Indicate Yes or No
Optional
What is Dependent #1's Relationship to you?
Optional
Name of Dependent #2.
Optional
Dependent # 2 - Date of Birth
Optional
Dependent #2 SSN
Optional
Dependent # 2 Sex - Indicate Male or Female
Optional
Does Dependent #2 use tobacco products? Indicate Yes or No
Optional
What is Dependent #2's Relationship to you?
Optional
Name of Dependent #3.
Optional
Dependent # 3 - Date of Birth
Optional
Dependent #3 SSN
Optional
Dependent # 3 Sex - Indicate Male or Female
Optional
Does dependent #3 use tobacco products? Indicate Yes or No
Optional
What is Dependent #3's Relationship to you?
Optional
Additional Dependents COVERED
If you have additional covered Dependents, please provide the information, as listed above, for each.
Optional
Dependents that will NOT be covered by insurance (claimed on taxes).
Name of Dependent #1 not covered.
Optional
Dependent #1 not covered Sex - Indicate Male or Female.
Optional
Dependent #1 not covered relationship to you.
Optional
Name of Dependent #2 not covered.
Optional
Dependent #2 not covered Sex - Indicate Male or Female.
Optional
Dependent #2 not covered relationship to you.
Optional
Name of Dependent #3 not covered.
Optional
Dependent #3 not covered Sex - Indicate Male or Female.
Optional
Dependent #3 not covered relationship to you.
Optional
Additional Dependent NOT Covered
If you have additional dependent in this category, please provide the above listed information for each in the space below.
Optional
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to
contact us
.
Per the terms of our
online privacy policy
we will not resell your information to any third-party.
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