Contact Get in touch with us The LEB Insurance Group – HQ 21 East 2nd Street, Suite 103 Fond du Lac, 54935 920-243-4100 Send us a message First Name*Last Name*Phone*Email* State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code*Preferred Language?EnglishSpanishFrenchTagalog/FilipinoCreoleHaitian CreoleMessageOptional Information to IncludeDo you have coverage now?YesNoWho is your current insurance through?Current PremiumCurrent Deductible/Co-Ins/CopayWhat do you primarily want to use health coverage for? Emergency Doctor Visits Rx What is more important to you? Better Coverage Lower Premiums Effective date to start your new Insurance on? Date Format: MM slash DD slash YYYY Do you have a Qualifying Life Event?YesNoCurrent Qualifying Life Event (within 60 days)Lost CoverageDivorced/MarriedNew DependentOtherDefine Other:Is there any particular Doctor or Clinic that you need to be In-Network?Is anyone applying for coverage planning on becoming pregnant this year?YesNoWould you like to see quotes with Dental or Vision?YesNoRange you feel you can afford monthly for this coverage?Expected adjusted gross annual household income for this year?Household size? (everyone on tax return)CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. Do you prefer more of a DIY approach? Get an INSTANT Affordable Care Act Quote here!
