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California Health Insurance Plan Quotes for Individuals and Families

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California health plan rates are subject to change. For more information, contact your broker or call a Health Net Sales Representative at 1‑877‑527‑8409.

IMPORTANT: Can you read this form? If not, we can have somebody help you read it. You may also be able to get this form written in your language. For free help, please call right away at 1-877-527-8409.

IMPORTANTE: ¿Puede leer este formulario? De no ser así, podemos hacer que alguien le ayude a leerlo.Para obtener ayuda sin costo, llame inmediatamente al 1-877-527-8409.

All fields requiredGeographic Information

Enter your Zip Code : 
State :  County : 

All fields requiredPlan Detail

Coverage Type :  Long Term

All fields requiredApplicant Detail

Type of Application



If you need coverage for just yourself.


If you need coverage for a combination of family members that includes at least one adult family member.

  Child(ren) Only

If you need coverage for your child or children only. Children 18 and under can be included on this coverage type.


Date of Birth



  • HMO Coverage is provided by Health Net of California, Inc., PPO Insurance Plans are underwritten by Health Net Life Insurance Company.
  • Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. Health Net® is a registered trademark of Health Net, Inc.

Effective Date of Coverage

Select the date you would like coverage to begin from the list below. Please note that your date options are determined by the date of your qualifying event(s) listed above.

Requested coverage
effective date:


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