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Additional Coverages Insurance Quote

Choose your coverage needs and we’ll match you with the right options.

Contact Info & Consent

Full Name *

Email *

Phone *

State *

Postal Code *

I consent to be contacted by phone, email, or text about insurance-related information.

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Coverage Basics

What type of supplemental coverage are you interested in? *

Dental

Vision

Accident

Critical Illness

Hospital Indemnity

Gap

Other (Please specify):

Who needs coverage?

Myself

Myself + Spouse

Family

Name (Myself)

Date of Birth (Myself)

Gender (Myself)

Male

Female

Tobacco (Myself)

Yes

No

Name(Spouse)

Gender(Spouse)

Male

Female

Date of Birth (Spouse)

Tobacco (Spouse)

Yes

No

Family Members?

Family Member Name 1

Family Member Gender 1

Male

Female

Non-binary

Family Member Age 1

Family Member Tobacco Use 1?

Yes

No

Family Member Name 2

Family Member Gender 2

Male

Female

Non-binary

Family Member Age 2

Family Member Tobacco Use 2?

Yes

No

Family Member Name 3

Family Member Gender 3

Male

Female

Family Member Age 3

Family Member Tobacco Use 3?

Yes

No

Family Member Name 4

Family Member Gender 4

Male

Female

Non-Binary

Family Member Age 4

Family Member Tobacco Use 4?

Yes

No

Family Member Name 5

Family Member Gender 5

Male

Female

Non-Binary

Family Member Age 5

Family Member Tobacco Use 5?

Yes

No

Family Member Name 6

Family Member Gender 6

Male

Female

Non-Binary

Family Member Age 6

Family Member Tobacco Use 6?

Yes

No

Family Member Name 7

Family Member Gender 7

Male

Female

Non-Binary

Family Member Age 7

Family Member Tobacco Use 7?

Yes

No

Family Member Name 8

Family Member Gender 8

Male

Female

Non-Binary

Family Member Age 8

Family Member Tobacco Use 8?

Yes

No

Family Member Name 9

Family Member Gender 9

Male

Female

Non-Binary

Family Member Age 9

Family Member Tobacco Use 9?

Yes

No

Family Member Name 10

Family Member Gender 10

Male

Female

Non-Binary

Family Member Age 10

Family Member Tobacco Use 10?

Yes

No

Family Member Name 11

Family Member Gender 11

Male

Female

Non-Binary

Family Member Age 11

Family Member Tobacco Use 11?

Yes

No

Family Member Name 12

Family Member Gender 12

Male

Female

Non-Binary

Family Member Age 12

Family Member Tobacco Use 12?

Yes

No

Family Member Name 13

Family Member Gender 13

Male

Female

Non-Binary

Family Member Age 13

Family Member Tobacco Use 13?

Yes

No

Family Member Name 14

Family Member Gender 14

Male

Female

Non-Binary

Family Member Age 14

Family Member Tobacco Use 14?

Yes

No

Family Member Name 15

Family Member Gender 15

Male

Female

Non-Binary

Family Member Age 15

Family Member Tobacco Use 15?

Yes

No

Current Coverage

Do you currently have any of these coverages?

Yes

No

Current carrier

Expiration date

Is this tied to an employer plan?

Yes

No

Who provides your coverage?

Would you like to see options that coordinate with your employer plan?

Yes

No

Preferences

What’s most important to you?

Keeping monthly costs low

Broad provider network (dentists / vision clinics)

Comprehensive benefits (higher annual maximums, lower copays)

Bundling with existing health or life coverage

Do you have any preferred providers?

Thanks for completing your request!

A licensed Fortune Shield advisor will review your info and compare Dental, Vision, and Supplemental plans to fit your needs.

Expect a call, text, or email within 24 hours.”

Schedule a Call: Book Now

Fortune Shield Insurance — Dental • Vision • Accident • Supplemental

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Fortune Shield is a licensed independent insurance agency. Not all products are available in all states. Eligibility and benefits vary by carrier and state. Enrollment subject to approval. Fortune Shield is not connected with or endorsed by the U.S. government or the federal Medicare program.

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