Under 65 Health Quote

HEALTH INSURANCE –
ACA ELIGIBILITY FORM

The Annual Open Enrollment Period starts November 1! This is your chance to review your current health insurance plan or explore new options that better fit your needs. Whether you’re looking for comprehensive coverage or specific benefits, we’re here to help you navigate the process.

The Open Enrollment Period runs from November 1 to January 15. Please complete the below form to get the process started. Our team is here to ensure you get the coverage you deserve.

Client Name

Address

City

State

Zip

County

Phone

Birthday

Are you a tobacco user?

Client Name

Address

City

State

Zip

County

Phone

Birthday

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?

Under 65 Health Quote

HEALTH INSURANCE – ACA ELIGIBILITY FORM

HEALTH INSURANCE –
ACA ELIGIBILITY FORM