Appointment Information Form

Appointment Request Form

Friendly Expert Advice

The easiest way to choose a plan and get enrolled is to speaking with one of our advisors. They are friendly, helpful, and they know what they are talking about.

If you would like our assistance in choosing and applying for an HSA-qualified health insurance plan, please fill out the form below completely to request a telephone appointment. This will give us the information we need to do an initial analysis of your situation. It will also give us the opportunity to review all available plans, so that we can be prepared to discuss the best options for your needs when we speak.

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We will then call you to schedule the time for the appointment. You may also call of office at 866-749-2039, and the receptionist will take this information over the phone and schedule a time.

Whether you do your own research and apply online, or let us help you out, you will find that we make the entire process easy and hassle-free.

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?

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