Screen Reader Mode Icon
EXIT

Question Title

* 1. What is your full legal name?

Question Title

* 2. What is your street address?

Question Title

* 3. What is your age?

Question Title

* 4. What is your date of birth?

Date

Question Title

* 5. What is your social security number?
(This is NOT required immediately, however in order to finalize your policy and avoid a phone call to verify, having this information will allow us to finalize your application for insurance much quicker if you are offered a free plan.

Question Title

* 6. How many dependents (spouse and children in the household)?

Question Title

* 7. How many people in the household need coverage including yourself?

Question Title

* 8. For dependents that need coverage, list Full Legal Name, Date of Birth, and Social Security Numbers.
(This is NOT required immediately, however in order to finalize your policy and avoid a phone call to verify, having this information will allow us to finalize your application for insurance much quicker if you are afforded a free plan.

Question Title

* 9. What is the estimated household income that will be reported on your taxes for the current year?(This would be your income plus your spouses income together if you are married.)(For an Individual income must be no less than $14,580 and no more than $21,780 for the annual period and for a family of four no less that $30,000 and no more than $45,000. See chart for reference.) You may still qualify for a free policy if your income exceeds what is listed in the chart however this graph displays exact qualification parameters for a free policy. FPL Chart

Question Title

* 10. What is your email?

Question Title

* 11. What is your phone number?

DISCLAIMER: By submitting your information you agree that Unified Wellness or its licensed representatives may use your information to find free or low cost healthcare and act as the agent of record on your behalf in delivering the best free policy, if qualified. We also have permission to contact you at the above-listed email or phone number. I understand that giving consent does not mean I am required to purchase anything. If you do not qualify for free healthcare, you will be contacted and provided options and afforded the opportunity to select one of our exclusive packages at no cost or obligation. 
0 of 11 answered
 

T