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.

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. Have you been diagnosed or treated by a member of the medical profession in the last 12 months for any of the following:
A: Cancer, cancer-related disease, or benign tumor?
B: Disease of the heart or blood vessels, or had a stroke?
C: Kidney disease?
D: Alcohol or drug abuse?
E: Lung, Emphysema, Chronic Bronchitis, COPD, Chronic Pneumonia, liver or blood disorder?
F: Emotional, nervous system, eating disorder, or mental health problems?
G: Ulcer, stomach or digestive disorder?
H: Arthritis, back, bones or joint disorder?
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