Quote Request for Private Health Insurance

Requested Effective Date
MM slash DD slash YYYY
Policyholder Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Tobacco Use*
Address*
Street Address City State ZIP Code
Phone*
Email*
Spouse and/or Dependent Information
Use the + icon at the end of each row to add additional rows as needed
First Name Last Name Date of Birth Gender Tobacco Use

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?
- Yes
- No
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 2022.
Estimated 2022 household income
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.
Signature*

Policyholder Information

First Name	Last Name	Date of Birth	Gender	Tobacco Use