AWCI Insurance Inquiry Form

This form provides AHP the necessary information to be able to advise you. It is not shared with any other entity and/or used for any other purpose. >Product availability, rates, and eligibility vary by state and individual circumstances. >No options available in AK, CA, CT, HI, MA, ME, NH, NJ, NY, RI, VT, and WA due to state restrictions.
*Required

MEMBERSHIP NUMBER
ARE YOU ELIGIBLE FOR AND/OR RECEIVING MEDICAID OR AN OBAMACARE SUBSIDY?* > MEDICAID >OBAMACARE 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.)

HOW LONG HAVE YOU BEEN UNINSURED?*
(Put N/A if you have insurance)

DESIRED EFFECTIVE DATE*

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