Under 65 Health Quote

HEALTH INSURANCE –
ACA ELIGIBILITY FORM

Client Name

Address

City

State

Zip

County

Phone

Birthday

Email

Smokers?

How many people in Household (How many people on tax return)

Will you file taxes in 2024? if not, you do not qualify, please file your taxes & then call us back.

What is your Expected Annual Household Adjusted Gross Income for 2024?

Are you employed or self-employed? Provide the Company Name & Phone Number

How many people need insurance?

Proposed effective date

Dependent/Spouse #1

Name

DOB

Dependent/Spouse #2

Name

DOB

Dependent/Spouse #3

Name

DOB

Dependent/Spouse #4

Name

DOB

Dependent/Spouse #5

Name

DOB

Who referred you to us?

We Can Take Care Of All Your Life & Health Insurance Needs…and Do Not Charge For Our Services!

”We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.”

Contact

Open Hours

Monday: Friday 9:00 AM – 5:00 PM Saturday: By Appointment Only. Sunday: Closed.

Consider joining MedicareJourney.org directory. OIG Agents receive a 10% discount. Ask for your discount code.

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HEALTH INSURANCE – ACA ELIGIBILITY FORM

HEALTH INSURANCE –
ACA ELIGIBILITY FORM