2021 SEP 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. Was everyone in the household born in the United States True False Question Title * 5. Address Physical Address Mailing Address City/Town State/Province ZIP/Postal Code County Email Address Phone Number Question Title * 6. Household members Spouse DOB Social Security # Child 1 DOB Social Security # Child 2 DOB Social Security # Child 3 DOB Social Security # Child 4 DOB Social Security # Child 5 DOB Social Security # Question Title * 7. Doctors you have and want to continue to see Question Title * 8. Is anyone in the household currently pregnant? Yes No Question Title * 9. Do you have any chronic conditions that require regular treatment? i.e. lab draws, MRI's etc...Please explain Question Title * 10. 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 * 11. 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.You can adjust your income levels at any point during the year. Question Title * 12. What is your qualifying event? Loss of Employer Coverage Loss of OHP or Medicaid in another state Moving to Oregon and lost/losing coverage in another state Turning 26 and lost/losing coverage from a parent Other Question Title * 13. Are you interested in any other lines of insurance? Dental Auto/Homeowners Insurance for your business Question Title * 14. Anything else you would like me to know? Done
