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Licensed Certified Field Broker / Agent

Your contact information will be provided to a BrokerAgent that has met or exceeded the requirements established by MyHIA.org in terms of professional skills and knowledge so that we are confident you will benefit from their assistance.  Furthermore, each enrolled and certified agent has made a MyHIA Pledge to serve you.

Completion of the top contact information is all that is required to initiate contact by one of the MyHIA.org certified agents serving your area.  However, if you take the time to complete the additional information requested, the agent will be all the more prepared to assist you when you are contacted.  Among other things, they will be able to pre-scan for plans available in your area that meet your health and other criteria specified.    

 

 

Please put me in touch with a licensed certified broker/agent

Check Here, if you would like to be contacted immediately.

(A text message will be sent to their telephone alerting them to your request.)

  Last Name:*  
  First Name:*  
  City:*  
  Zip Code:*  
  State:*  
  Telephone Number:*  
  Alternate Number:  
  Email address:*  
  Re-enter email address:*  
       
 

Notification that a Broker / Agent has been contacted will be sent to you

at the above email address

 
       
 

 

Age

Birth Date

(mm/dd/yyyy)

Height

 

Weight

 

Smoker

Taking

Meds

Self

Employed

  Applicant

ft ins

lbs

  Spouse

ft ins

lbs

 

Children's

Ages

Children Over 18 Full time students?

  Currently Insured?

Name Of Provider (s)  

 

Does anyone applying for coverage

have any pre-existing conditions?

(Please Specify)

  Interested In Small Business Group? 

How Many Employees?   

  Prefer: HMO   PPO

Interested In High-Deductible

FSA, HSA, HIA plan options?

The information entered will not be used for any purposes other than establishing contact with a local licensed Certified Field Broker / Agent. See Privacy Policy and Site Terms and Conditions tabs at the bottom of the page.

There is no charge for this service nor will you be charged any fee by the broker / agent contacting youYou are also under no obligation to purchase a Health Care Plan from anyone. Consider them strictly as a true “value-added” resource to assist you in reaching the best for your situation.

Should you elect to enroll with one of the certified Broker / Agent the Premium will be the same as if you went directly to the company.

     

 

 

Your satisfaction is our goalYour feedback is what gives teeth to the integrity of this program.  We utilize the information you privide us to improve the infomation on the site and to ensure that the broker / agents enrolled in our program meet or exceed your expectations.  Please use the Your Comments tab, located at the bottom of any page, to record your comments when appropriate.  We appreciate you taking the time to do so.   

 
 
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