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Individual Health Insurance Contact Info & Consent

Full Name *

Email *

Mobile Phone *

Zip Code *

(helps route based on state + carrier availability)

State *

I consent to be contacted by phone, email, or text about insurance-related information. I also authorize Fortune Shield and its agents to use the information I provide to prepare insurance quotes and plan recommendations.

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Current Coverage & Eligibility

If Employer Coverage – Who is covered?

Employer Coverage Only

Qualifying Event (if outside open enrollment: Nov 1 - Jan 15)

(This matters only if outside open enrollment)

PER YEAR - What is your estimated household modified adjusted gross income? *

Helps us determine subsidy eligibility for ACA or Medicaid options.

MAG:

The household modified adjusted gross income comprises an average of your adjusted gross income (AGI) and your taxable income.

Are you self-employed or 1099?

Self-Employed

Which best describes you? *

I (or anyone in my family) rarely go to the doctor and don’t take ongoing prescriptions

I (or anyone in my family) go to the doctor a few times a year, mostly for routine care

I (or anyone in my family) have ongoing conditions and/or take regular prescriptions

Do you take any prescription medications you’d like us to check for coverage?

You can list medication names only — no dosages or personal health details.

Do you have specific doctors or clinics you’d like to keep in your network?

Example: Dr. Smith at Ogden Clinic

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Accessibility Statement

Fortune Shield is a licensed, education-first protection resource. NPN: 1073776. 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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