Health Savings Account - Selected Benefits

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Houston Metro: 713-621-1440

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Request an Individual / Family HSA Insurance Quote

Please give information ONLY on persons who are to be included in the temporary health insurance quote.

"*" indicates required fields

Primary Insured

Name*

First Last

Zip Code*

Email*

Phone*

Birth Date

MM slash DD slash YYYY

Gender*

Male

Female

Tobacco Use*

Yes

No

Included in this quote:

Include Spouse

Include Children

Spouse Information

Spouse Birth Date

MM slash DD slash YYYY

Spouse Gender*

Male

Female

Spouse Tobacco Use*

Yes

No

Children Information

Child 1 Birth Date*

MM slash DD slash YYYY

Child 1 Gender*

Male

Female

Child 2 Birth Date

MM slash DD slash YYYY

Child 2 Gender

Male

Female

Child 3 Birth Date

MM slash DD slash YYYY

Child 3 Gender

Male

Female

Child 4 Birth Date

MM slash DD slash YYYY

Child 4 Gender

Male

Female

Child 5 Birth Date

MM slash DD slash YYYY

Child 5 Gender

Male

Female

Federal Subsidy Qualification

To determine if you qualify for a federal subsidy, please fill out the following information:

Household Size*

Number of people in your household.

Approximate Household Income*

What will your approximate household income be in 2025?

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Selected Benefits, Inc.

Steven Wendlandt (Owner/Agent)
FFM ID: swendlandt
NPN: 7437846
Texas Insurance License: 1197552
Arkansas Insurance License: 7437846

Group Health Insurance offered by iSure, LLC – a Selected Benefits, Inc. and AO Insurance Agency, Inc. partnership.

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Toll Free Phone: 866-270-6209
Local Phone: 713-621-1440
info@selectedbenefits.com
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Conway, AR 72034

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