Family and Individual Health Insurance | Get Me a Health Plan.com

In the 5-county Philadelphia area?

If you are a resident of Bucks, Chester, Delaware, Montgomery, or Philadelphia County, click here to get a quote.

Outside of the 5-county Philadelphia area?

If you are a resident of Pennsylvania (outside of the 5-county Philadelphia area) or a resident of the state of New Jersey, please fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

First Name

Last Name

Zip / Postal Code

Primary Phone Number

E-Mail Address

Date of Birth

Do you use tobacco?

Do you have insurance now?

Who is your current insurance carrier?

Are you married?

Should your spouse be included in the quote?

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Does your spouse use tobacco?

How many children should be included in the quote?

Child #1

Child #1 First Name

Is child #1 over 18?

Child #1 Date of Birth

Does child #1 use tobacco?

Child #2

Child #2 First Name

Is child #2 over 18?

Child #2 Date of Birth

Does child #2 use tobacco?

Child #3

Child #3 First Name

Is child #3 over 18?

Child #3 Date of Birth

Does child #3 use tobacco?

Child #4

Child #4 First Name

Is child #4 over 18?

Child #4 Date of Birth

Does child #4 use tobacco?

Child #5

Child #5 First Name

Is child #5 over 18?

Child #5 Date of Birth

Does child #5 use tobacco?

Child #6

Child #6 First Name

Is child #6 over 18?

Child #6 Date of Birth

Does child #6 use tobacco?

Child #7

Child #7 First Name

Is child #7 over 18?

Child #7 Date of Birth

Does child #7 use tobacco?

Child #8

Child #8 First Name

Is child #8 over 18?

Child #8 Date of Birth

Does child #8 use tobacco?

Child #9

Child #9 First Name

Is child #9 over 18?

Child #9 Date of Birth

Does child #9 use tobacco?

Effective Date