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Date        February 17, 2018, 8:05 pm

To receive a direct quote during open enrollment (November 15-February 15) from one of Goodwin Benefits' trusted health insurance carriers, please select from the following:


Missed the enrollment period? You may be eligible for a special enrollment outside of the open enrollment period. Click Here to learn more.

Or complete the questionnaire below and we'll do the shopping for you!

Individual Health Insurance Questionnaire

Primary Contact

First Name         Last Name

Phone#                          Fax# Email

Home Address             City State ZIP

Mailing Address (only if different)

List All Persons to be Insured

Date of Birth mm/dd/yyyy

Gender

Height

Weight

Tobacco Use

 

M

F

Yes

No

M

F

Yes

No

M

F

Yes

No

M

F

Yes

No

M

F

Yes

No

M

F

Yes

No

             

Current Medical Insurance:       None       COBRA       Group       Individual

Name of Carrier            Monthly Premium

Why Change Desired?

Any Other Info?            

 

 

To obtain a hard copy of request form, Click Here. Complete and fax to Carolyn Goodwin at (972) 503-4241