Individual and Family Plans Questionnaire

Please enable JavaScript in your browser to complete this form.

Referred by

Name *

First

Last

Address

Email *

Phone *

Best time of day to call

Age & D.O.B.

Are You Currently Insured

If no, why?

If Yes, name of and likes/dislikes of plan:

Tax credit?

Have you had a tax credit through the marketplace?

If plan is ending, when does it end and why?

Next year's estimated income

This year's household income

(or best estimate)

Current Insurance Company & Premium

Budget

(Desired monthly health insurance premium)

Deductible

Coinsurance

What Would You Like Covered?

Effective Date/Begin Date

Tobacco User?

Spouse/Child/Children’s Names, Age M/F & D.O.B.

Interested In: Dental/Vision

Accident/Critical Illness

Pre-Existing Conditions

(and last occurrance)

Prescriptions

Frequency and dosage

Doctors to find in Network

Follow up Appointment: Date/time

APP ID