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Individual Health Insurance Contact Info & Consent

Full Name *

Email *

Mobile Phone *

Zip Code *

(helps route based on state + carrier availability)

State *

By submitting this form, I agree that Fortune Shield Insurance Services and its licensed agents may contact me by phone, email, or text message to discuss insurance products, including health plans.
I understand that my consent is not required to make a purchase, and message and data rates may apply. My information will be used only to provide quotes and plan recommendations.

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Current Coverage & Eligibility

If Employer Coverage – Who is covered?

Employer Coverage Only

Qualifying Event (if outside open enrollment: Nov 1 - Jan 15)

(This matters only if outside open enrollment)

PER YEAR - What is your estimated household modified adjusted gross income? *

Helps us determine subsidy eligibility for ACA or Medicaid options.

MAG:

The household modified adjusted gross income comprises an average of your adjusted gross income (AGI) and your taxable income.

Are you self-employed or 1099?

Self-Employed

Which best describes you? *

I (or anyone in my family) rarely go to the doctor and don’t take ongoing prescriptions

I (or anyone in my family) go to the doctor a few times a year, mostly for routine care

I (or anyone in my family) have ongoing conditions and/or take regular prescriptions

Do you take any prescription medications you’d like us to check for coverage?

You can list medication names only — no dosages or personal health details.

Do you have specific doctors or clinics you’d like to keep in your network?

Example: Dr. Smith at Ogden Clinic

Call +1 801-997-8196

Email: [email protected]

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