Apply Online — Short-term Insurance

Receive Temporary Coverage Tomorrow!

Important Information

The online process should take 10 to 20 minutes. You will not be able to save your information and come back, so make sure you have enough time to complete the entire application. If there is no activity after 30 minutes, your session will end and the information you entered will be lost.

To complete the application you will need:

    Credit or Debit Card (Visa, Mastercard, Discover)
    Date of Birth (for each person applying)
    Social Security Number (for each person applying)
    Immunization Records (for applicants 6 months to 6 years old)

Who Can Apply?

    Permanent Arkansas residents who are U.S. citizens.
    Those who have not been previously insured by QuicChoice for more than 1 prior benefit period.
    Those between the ages of 6 months and 65 years old applying for individual coverage.
    Family, individual and spouse, or individual & child(ren), when oldest applicant is age 19 up to age 65.
    Individuals who are not on Medicaid, Medicare or any other health insurance plan. Review our MediQ65 Medicare supplement plans.
    Women who are not pregnant.
    Those who have not received (within the last five years), consultation or treatment for any of the following:
    • Liver disorders
    • Kidney disorders
    • Chronic obstructive pulmonary disease (COPD)
    • Emphysema
    • Diabetes
    • Cancer (other than skin cancer)
    • Heart or circulatory system disorders
    • Alcohol or drug abuse
    • Immune system disorders, including HIV infection or tested positive for HIV infection
    Minors age 6 to 11 months who have had 3 doses each of these immunizations:
    • HepB, DTaP, RV, IPV
    Minors age 12 months to 6 years who have had 3 doses each of these immunizations:
    • MMR, Varicella, HepA, HepB, DTaP, RV, IPV

Who is filling out this application?


This application is a legal document, which will become part of your contract if you are approved for coverage. It is very important that you provide all requested information and that it is accurate.

The information provided here will be used and disclosed only as permitted by our Privacy Policy which can be viewed at QualChoice.com.