Find the right coverage in minutes
OnePoint Insurance Agency offers a full suite of health and ancillary insurance products. Answer a few questions for a personalized quote — no obligation. A licensed agent will review and help you enroll.
What type of coverage are you looking for?
Pick the product that best matches your need. If you're not sure, pick the closest option — a licensed agent will help you compare.
What type of plan are you looking for?
This helps us narrow down plan options for you.
What's your date of birth?
We need this to check plan availability and pricing.
How many people are in your household?
Include yourself, spouse/partner, and any dependents you'll claim on taxes.
Annual Household Income
Include wages, self-employment income, Social Security, and investment income.
What's your gender?
Used for plan eligibility and pricing.
Do you use tobacco or nicotine?
4 or more times per week in the past 6 months. Affects plan pricing under Affordable Care Act regulations.
Is anyone on this application pregnant?
This can affect eligibility for Medicaid and certain programs.
What's your employment situation?
Tell us about your work
Enter the name of your employer and your job title or occupation.
How soon do you want coverage?
What's your name?
Use your legal name as it appears on your ID.
Do you have a Social Security Number?
Required by most Short-Term Medical carriers for underwriting and binding.
Enter your Social Security Number
Stored securely and used only for carrier underwriting and binding.
How can we reach you?
What's your home address?
Physical address only — no P.O. Boxes.
Is your mailing address the same as your home address?
What's your mailing address?
What's your marital status?
What's your tax filing status?
How you'll file federal taxes this year — used to check subsidy eligibility.
Are you a US citizen or US national?
This helps determine program eligibility.
How did you become a US citizen?
Do you have eligible immigration status?
Deferred Action for Childhood Arrivals (DACA) is not eligible. If unsure, choose "Prefer not to say" and a licensed agent will help.
Add anyone else who needs coverage
Include spouse/partner and any dependent children. If just applying for yourself, click Continue.
Have you had health coverage in the past 60 days?
Tells us whether you qualify for a Special Enrollment Period.
Did any of these happen in the past 60 days?
Qualifying life events can open a Special Enrollment Period outside open enrollment.
Are you a veteran or active duty military?
Have you received Advance Premium Tax Credits (APTC) before?
If yes, you'll need to reconcile on your tax return.
Are you currently incarcerated?
Required by the Affordable Care Act for eligibility determination.
Are you American Indian or Alaska Native?
Members of federally recognized tribes may qualify for special enrollment and cost-sharing.
Are you currently enrolled in Medicare?
Medicare eligibility affects Marketplace plan options and premium tax credit eligibility.
Would you like to add extra protection?
These plans can help reduce out-of-pocket costs and provide extra financial protection during unexpected situations. Select your preferences below.
Standalone dental and vision plans are often available alongside your health plan.
- Routine cleanings and exams
- Fillings and major dental work
- Orthodontic benefits (select plans)
- Eye exams
- Glasses and contact lenses
- Vision correction benefits
Accident plans can provide lump-sum cash benefits up to $30,000 for covered accidental injuries, emergency treatment, hospital stays, fractures, ambulance services, and more. Benefits are paid directly to you and can help with medical bills, lost income, or everyday expenses.
Pay up to $2,000/day for each covered hospital day. Helps with:
- Hospital stays
- Deductibles and copays
- Lost income & household bills
Lump-sum benefit up to $100,000 for serious diagnoses:
- Heart attack & stroke
- Cancer
- Major organ failure
Benefits are paid directly to you and can be used however you choose.
Please read the attestations
Select a response for each statement below.
I know that I must tell the program I'll be enrolled in within 30 days if information I listed on this application changes. I know I can make changes by contacting my licensed agent or by calling OnePoint Insurance Agency at (888) 899-8117. I know a change in my information could affect eligibility for member(s) of my household.
If anyone on your application is enrolled in marketplace health coverage and is also found to have Medicare coverage, the marketplace will automatically end their health plan coverage. They will get a notice before coverage is terminated in case they need to keep it or make changes. During all the months of overlapping coverage, they're responsible for paying the full cost for the marketplace plan premium and covered services.
Consent and tax agreements
Select a response for each statement below.
By signing below, I consent to my information being shared with my state's Medicaid agency and the Children's Health Insurance Program (CHIP) for the purpose of making a Medicaid or CHIP eligibility determination if my application fits specific criteria to be potentially eligible, or if I otherwise request Medicaid or CHIP eligibility directly.
I understand that any financial help I receive from the federal government through Advance Premium Tax Credits is connected to my taxes. I understand that I may owe taxes, or receive more tax credit, if my income for this year is different than what I estimated. I agree to file federal income taxes (jointly if married) and report the amount of Advance Premium Tax Credits received on my Tax Return for any year I have federal financial help to lower premium costs.
Electronic signature
I declare under penalty of perjury under the laws of the United States of America and the laws of the state in which I reside that the foregoing is true and correct. I understand and acknowledge that I will be subject to penalties under both State and Federal law if I knowingly or willfully provide false information in support of this application.
Type your full name below to sign electronically.
Review your application
Check everything and jump back to any section to edit. When ready, click Finalize to submit.
Submitting your application…
Please don't close this window.
Upload your supporting documents
To complete verification, please upload a clear photo or scan of the documents below. Once you're done, click Continue & Submit to finalize your application.
Application received!
Thank you — your application has been submitted. A licensed OnePoint agent will reach out within one business day to review your options and help you enroll.
A confirmation has been sent to the email on file. If you need immediate help, please call 888-899-8117.
To complete your enrollment, please sign the Income Verification Authorization and Consent to Contact documents below.
Sign your required documents
Your application has been received. Please complete both signatures below to finalize your enrollment. Click each button to open the document — it won't take over your screen.
Who needs coverage?
We'll tailor your options to the right plan structure.
What's your date of birth?
We need this to check plan availability and pricing.
What's your gender?
Used for medical underwriting.
Do you use tobacco or nicotine?
4 or more times per week in the past 6 months. This affects plan pricing.
Is anyone on this application pregnant?
Important: Short-Term Medical plans generally do not cover maternity or pregnancy-related care. This helps us guide you to the right product.
How soon do you want coverage to start?
Short-Term Medical plans can often start as soon as the next day.
How long do you need coverage?
Short-term plans typically offer terms from 30 days up to 12 months (state limits apply).
Why are you applying for Short-Term Medical?
This helps us recommend the right plan length and coverage level.
What's your name?
Use your legal name as it appears on your ID.
Do you have a Social Security Number?
Required by most Short-Term Medical carriers for underwriting and binding.
Enter your Social Security Number
Stored securely and used only for carrier underwriting and binding.
How can we reach you?
What's your home address?
Physical address only — no P.O. Boxes.
Is your mailing address the same as your home address?
What's your mailing address?
What's your marital status?
What's your employment situation?
Your height and weight
Used by carriers for medical underwriting.
Have you been diagnosed or treated for any of the following?
Select all that apply. Short-Term Medical plans typically do not cover pre-existing conditions, so accurate disclosure matters.
Are you currently taking any prescription medications?
Include daily medications, inhalers, injections, and specialty drugs.
List your current medications
Have you received medical treatment in the past 24 months?
Include hospitalizations, ER visits, surgeries, diagnostic tests, or ongoing specialist care (not routine checkups).
Describe the treatment(s)
Are any procedures, surgeries, or treatments currently planned or recommended?
Including anything your doctor has suggested but not yet scheduled.
Describe the planned procedure(s)
Add anyone else who needs coverage
Include spouse/partner and any dependent children. If just applying for yourself, click Continue.
Pick a deductible that fits your budget
This is what you'd pay out-of-pocket before the plan starts sharing costs. Higher deductibles usually mean lower premiums.
Preferred coinsurance split
After you meet the deductible, this is the percentage the plan pays vs. what you pay.
Maximum out-of-pocket you're comfortable with
The most you'd pay in a plan year before the plan covers 100%.
Network preference
Most Short-Term Medical plans use a PPO network. Let us know if you have a preference.
Have you had health coverage in the past 60 days?
Useful context for the carrier and for identifying any coverage gap.
Prior carrier details
Helps us identify potential credit for prior creditable coverage.
Interested in pairing with dental or vision?
Short-Term Medical typically does not include dental or vision. Standalone plans are affordable and can start the same day.
Do you currently have dental coverage?
Helps us identify waiting period credits.
What level of dental coverage do you want?
Higher tiers cover more procedures but carry higher premiums.
Does anyone on this plan need orthodontics?
Braces, clear aligners, etc. Ortho typically has separate waiting periods.
Are you OK with waiting periods for major services?
Most dental plans apply 6–12 month waiting periods for crowns, root canals, and ortho. Plans without waiting periods cost more.
Current dentist (Optional)
We can check which plan networks include your dentist.
Do you currently have vision coverage?
What do you primarily need vision coverage for?
Select the option that best matches. A licensed agent will recommend a plan.
How often do you typically get an eye exam?
Current vision provider (Optional)
We can check which plan networks include your provider.
Are you currently enrolled in Medicare Part A and Part B?
Medicare Advantage (Part C) requires enrollment in both Part A and Part B.
Medicare Part A & Part B effective dates
You can find these on your red, white, and blue Medicare card. Skip any you don't know.
Which enrollment period applies to you?
Not sure? A licensed agent will figure this out with you.
Do you also have Medicaid?
If you have both Medicare and Medicaid (dual-eligible), you may qualify for special Dual-SNP plans.
Primary care doctor (Optional)
We'll check which plan networks include your doctor.
Do you see any specialists regularly?
Cardiologist, endocrinologist, etc.
Which specialists?
Current prescription medications
Include name, dose, and frequency. Part D formulary matching uses this list.
Preferred pharmacy
Where do you typically fill prescriptions? This affects Part D pricing.
Scope of Appointment (SOA)
CMS requires us to document what Medicare products you want to discuss before an agent can review your options.
What's your occupation?
Used for underwriting. Higher-risk jobs may affect rates.
How would you describe your job's physical risk?
Do you regularly participate in any of these activities?
Select all that apply. Some carriers exclude injuries from specific activities.
Preferred accident benefit amount
Lump-sum benefit paid out for covered accidents.
Which optional riders interest you?
Select all that apply. These add specific benefits.
Preferred daily hospital benefit
Cash benefit paid per day of hospital confinement.
Include enhanced ICU benefit?
Typically pays 2–3x the daily benefit for ICU stays.
Have you been hospitalized in the past 2 years?
Does not include ER visits or outpatient procedures.
Describe the hospitalization(s)
Purpose of travel
Destination countries
List every country you'll visit. Some destinations have restrictions.
Travel dates
We use these to calculate trip duration and premium.
How many travelers?
Including yourself.
Citizenship
Some travel plans require specific citizenship or residency.
Any pre-existing medical conditions among travelers?
Some plans offer pre-existing condition waivers if purchased within 14 days of trip deposit.
Describe the conditions
Medical coverage limit
Maximum for emergency medical expenses while abroad.
Emergency evacuation coverage
Covers medical evacuation to an appropriate facility or back home. Essential for remote destinations.
Include trip cancellation coverage?
Reimburses non-refundable trip costs if you have to cancel for a covered reason.
Have you ever been diagnosed with any of these?
Critical Illness policies generally do not cover prior diagnoses. Select all that apply.
Family medical history
Have parents or siblings been diagnosed with any of these before age 60?
Current prescription medications
List your medications
Preferred lump-sum benefit
Cash payout upon diagnosis of a covered condition.
Which conditions are most important to cover?
Select the conditions you want the policy to cover. Broader coverage costs more.
Interested in a Return of Premium rider?
If you never file a claim, you get your premiums back at the end of the term. Costs more upfront.
Quick final acknowledgments
Please review the disclosures and acknowledgments below before signing.
Electronic signature
Type your full legal name exactly as you entered it. This serves as your electronic signature.
Review your application
Check everything and jump back to any section to edit. When ready, click Finalize to submit.
Submitting your application…
Please don't close this window.
Application received!
Thank you — your insurance application has been submitted. A licensed OnePoint agent will reach out within one business day with plan options, pricing, and next steps.
A confirmation has been sent to the email on file. If you need immediate help, please call 888-899-8117.