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Quote Request for Private Health Insurance
Quote Request for Private Health Insurance
Do you have a preferred KHI Agent?
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Choose Preferred Agent
Brenda Eckard
Doreen Coppinger
Melanie Myott
Lynsey Fraser
Christy Cline
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Use the + icon at the end of each row to add additional rows as needed
Current Coverage
Name of your current health insurance company
Do you currently receive a subsidy through the Marketplace to help cover the cost of your insurance?
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Are you, or anyone listed on this form, offered health insurance from their employer?
Income Information
You may be eligible for a subsidy/premium tax credit to help pay your healthcare premium. To determine if you are eligible please provide us with your estimated total household income for 2021.
Estimated 2021 household income
Please note that due to Government restrictions, Open Enrollment does not start until November 1st and ends on December 15th (unless you have a qualifying event such as loss of current coverage, marriage, divorce, etc.).
By signing my name below I acknowledge and agree that:
I have read the
Privacy Notice Statement Pertaining to Personally Identifiable Information
and I hereby authorize KHI Solutions to collect and use my PII to the extent reasonably necessary to assist in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHP's through the Marketplace, and/or applying for Federal subsidies, and any other health related plan.
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