We Specialize in the Health Insurance Needs of the Pennsylvania Self Employed

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Your information will not be sold, shared or transferred to a third party.

 

 

 

 

 

 

 

 Preferred Group Submittal - Short Form
 Estimated time to complete:  90 Seconds

Our Promise To You:

We will use the information that you have provided here to help you qualify for our Preferred Health Insurance Plan. We will not sell, rent or lease your name, email address, or phone number for any other purpose. The information that you provide will be held in the strictest confidence and not used for any other purpose. We DO NOT sell your information to the highest bidder!



Please note:  You do NOT have to be self employed to qualify for our coverage ....  Our plans are available to all residents of Pennsylvania.*

  
First Name *required
Last Name *required
Zip Code *required
Work Phone * required
Home Phone *  required
E-mail * required
  • Are you currently covered by a health insurance program?
  • Are you self-employed?    Yes     No
     
  • If yes, how many full time employees?
     
  • Do you want your Plan Design to include: 
     

Ages of persons to be insured:

  • Male:
    Date of birth (mm/dd/yy):    /  /   Tobacco User?
  • Female:
    Date of birth (mm/dd/yy):    /  / Tobacco User?
  • Child 1:
    Age
  • Child 2:
    Age
  • Child 3:
    Age
  • Child 4:
    Age

 

  • Please list any Prescription Medications:

          

  • In your own words, please list any Pre-Existing Conditions:

          

  • We are the Authorized Representative for Guaranteed Issue Health Insurance for the Self-Employed. Have you ever been declined health insurance?  
     
  • Is anyone pregnant? 

 

  • Which statement(s) best describe your current needs?

      I need insurance immediately.

      I am comparing rates to my current policy.

      My current rates are too high.

      My current insurance has been canceled.

        I am starting a business and no longer have insurance from my employer.

      The benefits from my employer have been reduced or are too expensive.

Help us to HELP YOU save time and money. Let us know when it would be most convenient for us to call.  We respect your time and privacy and our plan designer will identify themselves as being from Self Employed Insurance Pennsylvania. We do not employ telemarketers, only licensed non-commissioned professionals who have been trained to design a plan to meet your needs and your budget!

 I request a plan designer  to contact me at this specified day and time:.

Please select your appointment: 

 Day:               *required
 Best Time:     *required

  It may take a few seconds to process your request.

Thank you for taking the time to fill out this form. A professional plan designer will contact you at your specified time to assist you with your Pennsylvania Health Insurance decision.

 

Access to Affordable Pennsylvania Health Insurance Coverage for Self Employed Individuals and Small Business

*Subject to review of medical history. All plans may not be available in all states.