Help during Open Enrollment

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* 1. Your Name

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* 2. Zip code

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* 3. What county do you live in?

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* 4. Do you currently have insurance?

Yes, an individual/family plan

Yes, Medicaid (T19 or Badgercare)

Yes, Medicare

Yes, an employer group plan

No, I am currently uninsured

Something else

Other (please specify)

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* 5. How would you like us to contact you?

Phone

Thank you! Someone from our office will be in touch soon about scheduling an appointment to help you look at insurance options for 2019. Open Enrollment runs November 1st to December 15th. If you would like further info, please call us at 414-797-3408 or email info@wihia.com. If you are losing coverage and need help now, please call us rather than completing this form.