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Home > Health > Individual or Family Medical Quote Request Form
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Individual or Family Medical Quote Request Form


 You have a lot of options and maybe even some questions when it comes to health insurance. Did you know using an Agent to help you understand the complexities of the Affordable Care Act and Medicare will not cost you a penny?  Simply invest a few minutes of your time to complete the form below and one of our licensed & certified Agents will reach out to help you navigate, shop, compare, and purchase the plan that’s right for you. 



Personal Information
First Name *
Last Name *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Date of Birth *
/ /
Number of Dependents *
Number of families living in home?
Ages of Children (separated by commas)
Additional Information
Additional Comments
How did you hear about us?
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Location
621 North College Road
Suite 103
Twin Falls, ID 83301

Local: (208) 734-5932
Toll Free: (877) 734-5932
Fax: (208) 944-2314
Email: tammy@hplanpartners.com
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