2021 Open Enrollment Paperwork Question Title * 1. Full Name (primary household member to handle insurance) Question Title * 2. DOB Primary DOB Date Question Title * 3. Social Security Number Question Title * 4. Were you and everyone in your household born in the United States?If you were not born in the United States documentation of citizenship will be required at the time of your appointment. Yes No Question Title * 5. Contact Information Physical Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code County Email Address Phone Number Question Title * 6. Mailing Address Mailing Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Question Title * 7. How many total household members do you have as listed on your 2021 tax return? Include spouses and any tax dependents.If you are unsure who to list please refer back to the email with the link to this paperwork and see the attachment "How to estimate household size" Question Title * 8. Household members Spouse DOB Social Security # Applying for coverage? Child 1 DOB Social Security # Applying for coverage? Child 2 DOB Social Security # Applying for coverage? Child 3 DOB Social Security # Applying for coverage? Child 4 DOB Social Security # Applying for coverage? Child 5 DOB Social Security # Applying for coverage? Question Title * 9. Doctors you have and want to continue to see Question Title * 10. Is anyone in the household currently pregnant? Yes No Question Title * 11. Do you have any chronic conditions that require regular treatment? i.e. lab draws, MRI's etc...Please explain Question Title * 12. List any prescriptions (is it a generic, please include the dose) that you are currently taking and would like to have covered in your new health plan. Question Title * 13. Predicted 2021 ANNUAL HOUSEHOLD IncomePlease include all income for any household member that is on your tax return***Adjusted Gross Income***Please note that if your income changes you MUST contact our office immediately to report your new income amount. We require the notice in writing. Tax credit/Subsidy amounts are based on your estimated income reported here. If your estimates are too low you may owe money back on your tax return. If you estimate your income too high you may be eligible for a tax credit/refund with your tax return. BY LAW our office is unable to decide what your estimated income will be. If you are unsure how to estimate your future income please see the original email where this link was provided and see the "how to estimate your income attachment" or talk to your accountant. You can adjust your income levels at any point during the year. Question Title * 14. What source/s are your incomes coming from? Please explain... Question Title * 15. Are you interested in any other lines of insurance? Dental Auto/Homeowners Insurance for your business Question Title * 16. Anything else you would like me to know? Done
