Questionnaire

Basic Information

Do you have existing insurance through your current or former employer?

Yes, currently employed Yes, former employer No

Please select the employment type

What is your employer’s name?

Please provide employer's name

State

Please provide employer's state

What is your ZIP code?

Please provide zipcode

Your age

Please provide your age

Your sex

Female Male

Please select your sex

Are you a tobacco user?

Yes No

Please select tobacco user

Family

Are you married?

Yes No

Please select your martial status

Age of your spouse?

Please provide your spouse age

How many children do you have?

Income and Coverage

Anticipated annual income

Please provide annual income

Your monthly portion of the premium

Please provide premium amount

Employer’s portion of the premium

Total premium

If you've lost your job, Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows you to keep your insurance for 18 months. We will help you determine whether there are cheaper options by using the information above.

Upload your Plan Benefits

Why do we ask about this?

We need to know the current coverage you have under your existing plan in order to compare with all other plans, available in your area. This is usually a PDF document, which Employer or a Health Insurance provide to you with the information about coverage, copay, coinsurance, in and out of network, etc.

Upload files

Health Insurance Usage

Low

I expect a Low use of health services—1-2 doctor visits, 1 specialist visit, no prescription drugs, 1-2 lab tests, no hospital visits, no emergency room.

Moderate

I expect a Moderate use of health services – 6-8 doctor visits, 2-4 specialist visit, 1-2 prescription drugs, 4-5 lab tests, 1 hospital visits, 1 emergency room

High

I expect a High use of health services – 12 doctor visits, 6 specialist visit, 1-2 prescription drugs, 8 lab tests, 3-5 hospital visits, 1-2 emergency room

Please provide your health option

Contacts

Based on the information you’ve provided, we will recommend the best insurance plan for you. If you upload your current plan’s set of benefits, we will analyze each document and provide additional input from our algorithm.

We will use your contact information below to share your best insurance options.

First Name

Please provide your first name

Last Name

Please provide your last name

Phone

Please provide your mobile

Please provide your email

I AGREE to the general terms of this application.

Please provide your email

General terms of the application assume that by clicking the button below, Nebula Health may use the data I provided for the purpose of assisting me with finding the best health insurance plan. I give Nebula Health permission to create my personal, secure account and contact me when needed with health insurance-related information related to my application. The use of this data is in compliance with Nebula Health’s Privacy Terms.

Find the Best Plan

HEALTH PLAN QUESTIONNAIRE

Basic Information

Family

Income and Coverage

Why do we ask about this?

Health Insurance Usage

Contacts

Thank you for submitting the application

HEALTH PLAN QUESTIONNAIRE

Basic Information

Family

Income and Coverage

Why do we ask about this?

Health Insurance Usage

Contacts

Thank you for submitting the application

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