Legacy Insurance Solutions

Health Insurance Intake Form

Enroll Prime Health Plans

Contact Information

Personal Details

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🛡 AES-256 Encrypted

Why we collect your SSN: Your Social Security Number is required for health insurance enrollment and identity verification. Your SSN is encrypted using AES-256 military-grade encryption before transmission and is never stored in plain text. Only authorized personnel with the decryption key can access it.

Current Insurance

Coverage Details

Simplified Issue Medical Questions

Please answer each question honestly. Your answers help us determine the best plan options for you.

1. Are any applicants:
A: On COBRA and considered disabled?
B: Currently NOT working or missed 10 or more consecutive days of work in the last 12 months due to injury or illness?
2. Are any covered persons contemplating treatment or hospitalization, been advised to seek treatment, or been scheduled for hospitalization and/or surgery within the past 12 months?
(Other than for routine childbirth without complications)
3. Does any applicant have:
A: Any medical or test results pending, or a medical service that has not yet been performed?
B: Any applicants currently pregnant or plan to become pregnant in the next 12 months?
4. Has any applicant ever:
A: Been diagnosed with chronic kidney disease, kidney failure, or required dialysis?
B: Been diagnosed with Type 1 diabetes?
C: Been diagnosed with Type 2 diabetes with complications (such as neuropathy, kidney disease, or retinopathy)?
D: Been diagnosed with Lung, Emphysema, Chronic Bronchitis, COPD, Chronic Pneumonia, pulmonary fibrosis, or another chronic lung disease requiring oxygen?
E: Been diagnosed with liver or blood disorder?
F: Been diagnosed with a severe mental health condition (such as schizophrenia, bipolar disorder, or any mental illness requiring hospitalization), or is any applicant currently receiving counseling or therapy for a mental health condition?
G: Been diagnosed with HIV, AIDS, any other serious immune deficiency disorder, or an autoimmune disease such as Crohn's disease, ulcerative colitis, lupus, multiple sclerosis, or rheumatoid arthritis?
H: Been diagnosed with a neurological disorder (ALS, Parkinson's disease, multiple sclerosis, muscular dystrophy, or an uncontrolled seizure disorder)?
I: Been diagnosed with or treated for cancer (other than fully removed basal cell skin cancer)?
J: Had a heart attack, heart surgery, angioplasty, stent, heart failure, stroke, TIA, or other serious vascular disease?
K: Been treated for substance or alcohol dependency in the past?
L: Received an organ transplant?
5. Within the past 12 months, has any covered person had an ongoing condition likely to cost $5,000 or more per year for treatment (including prescription) for a serious continuing claim due to a mental or physical disorder or any other medical condition?
If you are unsure of a medication cost, please visit GoodRX.com and type in the medication.

Additional Information

What happens next: After submitting, you will be redirected to schedule a call with Legacy Insurance to review and recommend coverage options for you.

🔒 Protected Health Information

By submitting this form, you consent to the collection and secure handling of your personal and health information by Legacy Insurance Solutions for the purpose of providing health insurance quotes and enrollment services. Your data is transmitted over HTTPS and sensitive information (SSN) is encrypted with AES-256 before storage. We do not sell or share your information with unauthorized third parties.

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Application Received!

Schedule a call below to review your coverage options.

Questions? Email support@legacyinsuranceco.com