Request a Quote

  1. Submit information below for quote comparison
  2. Review proposals for desired option (you will receive via email within 48 hours)
  3. Enroll online with Simplified Enrollment Process
Agent: Bryan Link
Email: blink@naught-naught.com
Phone: 573-874-3102 or 800-245-5727

All information is confidential

    Quoting Information

    Name:*
    Employer Name (if applicable):
    Phone:*
    Email:*
    Address:*
    City, State:*
    Zip:*
    County:*
    DOB:*
    Gender:*
    Tobacco:*

    Family Members

    Spouse:
    DOB:
    Gender:
    Tobacco:
    Child 1:
    DOB:
    Gender:

    I am also interested in quotes regarding:
    DentalVisionLife

    Enrollment Information Form

      Personal Information

      First Name
      Social Security Number
      Do you plan to file a federal income tax return NEXT YEAR?
      You can still apply for coverage even if you don't file a federal income tax return.


      a. Will you file jointly with a spouse?
      If yes, write name of spouse:

      If yes, provide Social Security Number of spouse:

      b. Will you claim any dependents on your tax return?
      If yes, list name(s) and Social Security Number(s) of dependents:

      Name:

      SSN:

      c. Will you be claimed as a dependent on someone's tax return?
      If yes, please list the name of the tax filer:

      How are you related to the tax filer?

       

      Current Job:

      Employer Name

      Employer Address

      City

      State

      Zip Code

      Employer Phone Number

      Wages/tips (before taxes)
      How much?

      If self-employed, answer the following two questions:
      a. Type of work:

      b. How much net income (profits once business expenses are paid)
      will you get from this self-employment this month?

      How much?
       

      Spouse's Job:

      Employer Name

      Employer Address

      City

      State

      Zip Code

      Employer Phone Number

      Wages/tips (before taxes)
      How much?
       
      If self-employed, answer the following two questions:
      a. Type of work:

      b. How much net income (profits once business expenses are paid)
      will you get from this self-employment this month?

      How much?
       

      Other Income

      Fill in all that apply, and give the amount and how often you get it.
      NOTE:You don't need to tell us about income from child support, veteran's payments, or Supplemental Security Income (SSI).

      How much?
      How often?

      How much?
      How often?

      How much?
      How often?

      How much?
      How often?
       

      Deductions

      Fill in all that apply, and give the amount and how often you pay it. If you pay for certain things that can be deducted on a federal income tax return,
      telling us about them could make the cost of health coverage a little lower.
      NOTE: You shouldn't include child support that you pay, or a cost already considered in your answer to net self-employment.

      How much?
      How often?

      How much?
      How often?
      Your total income this year
      How much?
      Your total income next year (if you think it will be different)
      How much?
       

      Your Family's Health Coverage

      Is anyone listed on this application offered health coverage from a job?
      Check yes even if the coverage is from someone else's job, like a parent or spouse, even if they don't accept the coverage.

      Is anyone enrolled in health coverage now?

       

      Information about current health coverage

      Name of person enrolled in health coverage

      Type of coverage:

      If it's employer insurance:
      Name of health insurance company:

      Policy/ID number

      If it's individual coverage
      Name of health insurance company:

      Policy/ID number

       

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