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VitalGuard Healthcare Solutions
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Intake form
Help us serve you better
Name
*
Email address
*
What is your primary reason for seeking health coverage?
Please select at least one option.
Individual health insurance
Family health insurance
Medicare
Medicaid
Short-term health insurance
Dental insurance
Vision insurance
Which types of health coverage are you interested in?
Please select at least one option.
HMO (Health Maintenance Organization)
PPO (Preferred Provider Organization)
EPO (Exclusive Provider Organization)
POS (Point of Service)
Health Savings Account (HSA) compatible plans
Catastrophic plans
Supplemental insurance
How many individuals will be covered under the policy?
Select
1
2
3
4
5 or more
What is your age group?
Select
Under 18
18-25
26-35
36-45
46-55
56-65
65 and older
Do you have any pre-existing conditions?
Select
Yes
No
What is your estimated annual household income?
Select
Under $25,000
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 - $149,999
$150,000 and above
Are you currently covered under any health insurance plan?
Select
Yes
No
What is your preferred method of contact?
Select
Email
Phone
Text message
Additional questions or comments
Submit
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