Annual Policy Review

Annual Insurance Policy Review
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Every year HSA for America clients are offered their Annual Comprehensive Policy Review, at which time we will research competitive options to make sure they are in the plan that offers them the best value. As independent brokers, our loyalty is to our customers.
If you would like a complementary review of your current plan compared to your best HSA options, fill out the form below. One of our advisors will do some preliminary research, and someone from our office will call to schedule a time for you to speak with them about your options.
All information will be kept confidential, and is requested solely for the purpose of providing you rate and policy information (see our Privacy Statement). All consultations are backed by our Extremely Satisfied Guarantee.
Please note: ALL information must be filled out completely before we can confirm your appointment.

Contact Information (* Required)

First Name: *

Last Name: *

Email: *

Phone: *

Fax:

Street Address: *

City: *

State: *

* Plans are only available in the listed states.

Zip Code: *

Date of Birth: *

Insurance Information (* Required)

Sex / Smoker *

Sex: Smoker:

Current Insurance Information:*

	Plan Name/Type:
	Monthly Premium:
	Deductible:

Additional Family
Members:

Sex	DOB	Smoker?

Is any family member currently pregnant?
(Plans cannot be written until after the baby is born. When is the due date?):

Does anyone that will be applying for coverage have diabetes, heart disease, or any other pre-existing medical conditions?

Is anyone currently taking medication?
(If so, what is the reason,
and what is the medication?)

Why are you interested in an HSA-qualified plan?

Are there any particular plans which you have looked at and are considering?

When would you want your new plan to become effective?

Have you reviewed your instant quotes (Y/N):

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Who referred you to
HSA for America?