Insurance Application
Do you have a registered business (LLC, PLLC, S Corp, or C Corp)?
*
Required
Yes, I have a registered business (LLC, PLLC, S corp, C corp, etc.)
No, I'm self-employed / 1099 without a registered business
Company Tax ID (EIN)
Company Name
*
Required
Name
*
Required
First Name
Required
Last Name
Email
*
Required
Preferred Phone
*
Required
Home Zip Code
*
Please note plans are currently not available in NY, MD, ID, ND, SD. If you have 5 or more employees in MD, ID, ND, or SD, we do have other options. Complete the form to learn more.
Required
Postal / Zip Code
Desired Effective Date
*
Required
This is not a guarantee of coverage by this date.
MMM-yyyy
Association Name
*
Required
ONE Healthcare
How many W2 employees do you have? (this doesn't include you)
*
Required
Include info for employees aside from yourself.
How will you provide employee emails?
We will need employee emails to send them each a Personal Health Questionnaire. Manual Entry = Best for groups under 15 employees\ CSV = Best for groups over 15 employees. Upload a CSV with columns: First Name, Last Name, Employee Email.
Manual Entry
CSV Upload
File Upload
If you have 15 or more employees, please upload your census file.
Upload file
Choose File
Employee Roster
-- No Fields Available --
Name
Employee Email
Add Entry
Add Entry
Name
N/A
Employee First Name
Employee Last Name
Employee Email
N/A
Name
N/A
Employee First Name
Employee Last Name
Employee Email
N/A
PHQ Send Status
Sent
Not Sent
PHQ Send Count
Lead Source
*
Required
Marketability
*
Required
Yes
No
Lead Priority
Cold
Warm
Hot
Lifecycle Stage
Lead
Engaged
MQL
SQL
Requirement Type
PHQ
Census
PHQ Process ID
Submit
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OK
Done