Under 65 Health Quote

HEALTH INSURANCE – ACA ELIGIBILITY FORM

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 2025?

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?