Health Insurance for the Quad Cities

(866) 440-1885

Health Insurance Application

If the agent finds a $0 ACA Health Insurance plan, do you want him to enroll you automatically? *

YES

NO

Would you like dental coverage as well? *

YES

NO

Would you like the agent to show you how to get your medical deductibles and out-of-pocket medical expenses covered? *

YES

NO

Monthly Budget For Health Insurance *

$

What is realistically the most you would be willing to spend each month on your health insurance package. We will try to get you the best package of coverage that fits within your personal budget.

Which of the following applies to you? *

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

Gender *

Tobacco User? *

Date of birth *

What is your employment status? *

Are you currently on Medicare or Medicaid *

What is your projected annual household income for this upcoming year? (This includes all wage earners in the household) *

Do you currently have health insurance? *

Do you have a Primary Care Physician (Doctor) that you want to keep? *

Physician Full Name *

Name of Physician's Practice *

Physician's Practice Address *

Please Select your Marital Status *

Please enter your Spouse's First Name *

Please enter your Spouse's Last Name *

Please select your Spouse's Gender *

Is Spouse a Tobacco User? *

Please select your Spouse's Income *

Please enter your Spouse's Date of Birth *

Do you wish to enroll your Spouse? *

Do you have tax dependents (typically children)? *

Number of Tax Dependents *

Enter Tax Dependent's information below

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

Enter Tax Dependent's Information Below

First Name *

Last Name

Date of Birth

Do you wish to Enroll this dependent as well? *

Enter Tax Dependent's Information Below

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

Enter Tax Dependent's Information Below

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

Enter Tax Dependents Information Below

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

Consent

I give my permission to William Mohring to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

1. Searching for an existing Marketplace application;

2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums;

3. Providing ongoing account maintenance and enrollment assistance, as necessary; or

4. Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes.

I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by emailing [email protected]

I, William Mohring, a licensed and experienced health insurance agent, hereby provide this attestation to acknowledge your agreement to the contents outlined below. By affixing your signature below, you respectfully request me or my agency affiliates to enroll both yourself and/or your family in the most suitable zero premium ACA plan available.

Please note that if there are no zero premium health plans available in your area based on the provided information, we will inform you of the available plans and seek your consent before proceeding with enrollment.

In addition to enrolling you in the optimal ACA plan, you authorize me or my agency to access your healthcare.gov account and submit the necessary information as required, in accordance with the details provided.

By signing below, you acknowledge the following:

You agree to the terms and conditions outlined in this attestation.

You respectfully request my expertise or that of my agency affiliates to enroll you and/or your family in the most suitable zero premium ACA plan available.

In the event that no zero premium health plan is available in your area, you understand that we will disclose the available plans and seek your consent before proceeding with enrollment.

You authorize me or my agency to access your healthcare.gov account and submit the necessary information as required.

William Mohring

NPN: # 8725281

(866) 440-1885

[email protected]

Enrollment Agreement *

Clear

You qualify for health insurance on the exchange if . . .

You are self-employed, an independent contractor, or freelancer.
You lost your job (and health insurance because of it).
You no longer qualify for state Medicaid.
You recently had or adopted a child.
You recently were married or divorced.
You recently changed your residence.
You were recently released from jail.
The lowest cost insurance at your work is more than 9% of your monthly income.

Our health insurance application is quick and easy. It takes only 5 minutes to fill out. Once complete, we will email you the best 3 options that fit within your budget.

If you only want a NO COST plan, you can choose to have us automatically enroll you so that we do all the legwork and you just wait for your insurance cards in the mail.

Privacy Policy | Terms & Conditions | HIPAA Privacy Statement

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day / 7 days a week). If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.

Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.

MohringInsurance.com is the web- and phone-based insurance portal utilized by Mohring Insurance Services, LLC. Beneficiaries may be connected by licensed insurance agents of Mohring Insurance Services LLC who are licensed to transact business as insurance agents in 39 states.

Not all licensed insurance agents with Mohring Insurance Services LLC are licensed to sell all products. Service and product availability varies by state. Agents of Mohring Insurance Services LLC work with Medicare enrollees to explain Medicare Advantage, Medicare Supplement Insurance, and Prescription Drug Plan options. Agents of Mohring Insurance Services LLC are licensed and certified representatives of Medicare Advantage HMO, PPO, and PPFS organizations and stand-alone prescription drug plans. Each of the organizations we represent has a Medicare contract. Enrollment in any plan depends on contract renewal.

Licensed insurance agents may be compensated based on a consumer's enrollment in a health plan. No obligation to enroll. Licensed agents cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled.

Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

Medicare has neither reviewed nor endorsed this information.

Licensed insurance agents required to comply with all applicable federal laws, including the standards established under 45 C.F.R. § 155.220(c) and (d) and standards established under 45 C.F.R. § 155.260 to protect the privacy and security of personally identifiable information.

The plans we represent do not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or religion. To learn more about a plan’s nondiscrimination policy, please contact the plan.

For a complete list of available plans please contact 1-800-MEDICARE, TTY 711, 24 hours a day/7 days a week or consult www.medicare.gov.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Medicare beneficiaries may also enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.

Every year, Medicare evaluates plans based on a 5-star rating system.

You are not required to provide any health related information unless it will be used to determine enrollment eligibility.

MohringInsurance.com is not connected with or endorsed by the United States government or the federal Medicare program.

Rates are reviewed periodically and are subject to change in your state.

Cost Estimates are based on the information entered on Get Started, using data about past experiences by beneficiaries with similar attributes and the premiums and benefits provided by the plan. Actual costs may vary. Monthly medical costs are represented by annual figures divided evenly per month.

Licensed sales agents/producers may be compensated based on your enrollment in a health plan.

Medicare Supplement Plans are not connected with or endorsed by the U.S. Government or the federal Medicare program.

Preference Score based on the answers provided within "Other Preferences" page in Guided Help.

For plans that provide drug coverage, the formulary may change during the year.

Health Insurance for the Quad Cities

Health Insurance Application

Consent

You qualify for health insurance on the exchange if . . .

© 2025 Mohring Insurance Services LLC | Davenport, IA. | (866) 440-1885

Privacy Policy | Terms & Conditions | HIPAA Privacy Statement

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Rates are reviewed periodically and are subject to change in your state.

Medicare beneficiaries may also enroll in Medicare plans through the CMS Medicare Online Enrollment Center located at https://www.medicare.gov.