PBA Insurance Inquiry Form

This form provides us the necessary information to be able to advise you. It is not shared with any other entity and/or used for any other purpose. *TERMS OF SERVICE: This program is only available to those holding a current PBA Student, Preferred, Business of 1,or Business membership. Membership does not guarantee eligibility for insurance policies. We advise what is best for each member based on his or her situation with the options available within the healthcare system.* Product availability, rates, and eligibility vary by state, individual circumstances, and insurance companies' guidelines. There are no options available in AK, CT, HI, MA, ME, NH, NJ, NY, RI, VT, and WA due to state restrictions.
*Required
I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS OF SERVICE NOTED ABOVE* >Type "Yes" in order to proceed

ARE YOU ELIGIBLE FOR AND / OR RECEIVING MEDICAID OR A MARKETPLACE SUBSIDY?*

MEMBER INFORMATION
FIRST & LAST NAME*
RESIDENTIAL ADDRESS*
CITY*
STATE*
ZIP*
COUNTY*
EMAIL*
PHONE*
GENDER*
DATE OF BIRTH*
TOBACCO USER?*
HEIGHT & WEIGHT*
ANY PRE-EXISTING HEALTH CONDITIONS IN THE LAST 5 YEARS?*
If yes, please include the details (diagnoses, medications, etc.).

SPOUSE INFORMATION (IF TO BE INCLUDED)
FIRST & LAST NAME
GENDER
DATE OF BIRTH
TOBACCO USER?
HEIGHT & WEIGHT
ANY PRE-EXISTING HEALTH CONDITIONS IN THE LAST 5 YEARS?
If yes, please include the details (diagnoses, medications, etc.).

CHILDREN INFORMATION (IF TO BE INCLUDED)
Please include the full name, gender, DOB, height, weight, and any health conditions for each child.
CHILD 1
CHILD 2
CHILD 3
CHILD 4
CHILD 5

ANYONE PREGNANT?*
If yes, please include the due date.

INSURANCE PRODUCTS OF INTEREST*

REASON FOR DESIRING ASSISTANCE*
(Job change, premium too high, poor network, not insured, etc.)

IF NOT INSURED, HOW LONG HAVE YOU BEEN WITHOUT?*
(Put N/A if you are insured)

DESIRED EFFECTIVE DATE?*

PLEASE PRESS SUBMIT AND WE WILL CONTACT YOU WITHIN TWO BUSINESS DAYS.