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Contact Name: *
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Address Street:
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City:
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Zip Code: *
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(5 digits)
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County: *
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State: *
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Daytime Phone: *
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Email: *
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Part l:
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If you are interested in determining if you qualify for financial assistance complete this section (if you do not want to apply for a subsidy, skip to Part ll)
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Tax Return:
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How many people will be on your Federal Tax Return for 2016?
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Income:
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Based on your best guess, what will be your total household income in 2016?
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Pregnant or Disabled?:
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Are you, or anyone to be insured, currently pregnant or disabled?
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Part ll:
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About you- Who do you want to have insured?
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Person 1: Name
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Date of Birth:
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Relationship:
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Tobacco Use:
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Person 2: Name:
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Date of Birth::
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Relationship::
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Tobacco Use:
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Person 3: Name:
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Date of Birth::
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Relationship::
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Tobacco Use:
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Part lll: *
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Do you Currently have health insurance?
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IF YES::
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Who is your current carrier:
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IF YES::
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What is your current deductible:
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IF YES::
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What is your current monthly premium:
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Part lV
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What type of plan are you looking for in 2016? Price vs Benefits ? Deductible?
Gold - Low Deductible of $500 -$1000
Silver - Medium Deductible of $2000 -$3000
Bronze - High Deductible of $4500 -$6,850
HSA Plan - (Health Savings Account)
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Physician?:
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I have a physician that I would like to stay with:
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Budget?:
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What is your budget for your monthly premium?
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Part V:
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Do you have a preferred Insurance Carrier?
AnthemCigna Humana
KaiserRMHPUnitedHealthOne
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Security Code: *
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