Let's get started!

I'm excited to help you with your health insurance!

STEP 1: Complete the form below.

The first step is to complete the form below with as much information as possible. This enables me to better understand your needs and pull accurate quotes.

STEP 2: Schedule a call with me.

Once you submit the form, you will receive a confirmation email with a link to schedule a call with me. If you don't receive this email or if you have any questions, please send an email to kathy@wiswellinsurance.com.

Tell Me About Yourself!

Please review the form.

First Name *

Last Name *

Email *

Phone Number *

Date of Birth *

Family members, if applicable. (Include names and dates of birth.)

Zip Code (If home and mailing addresses are different, use home address). *

County (If home and mailing addresses are different, use home address). *

MAGI (An estimate of your Modified Adjusted Gross Income for the year you are seeking coverage. Please ask a tax professional if you are unsure; we are unable to advise regarding this.) *

Doctors (Including your PCP and any specialists you'd like in-network.)

Facilities you'd like in-network.

Prescriptions you are taking. Please include dosage.

Please note, we are now outside of the open enrollment period (Nov 1 - Dec 15) and you will need a qualifying event in order to enroll in a health plan. Please list your qualifying event and associated date below.

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