Health Insurance Account Information Date MM slash DD slash YYYY Client: Prepared By:*Alonso, FrancescaAldana, SerigoBalco, CraigBlue, TiffanyD’Hondt, MichaelDiaz, LisaDreday, BabsDugan, LeeAnnGodwin, DavidHill, CaitlinHilliard, SherrinHolmes, ShellyJennings, MatthewKennedy, BrewaLamb, KaylaLevi, DouglasLong, TinaLuciano, CarmenLynch, BrookeMella, TonyMyers, TamaraNazario, JimmyO Sullivan, MarkPeshak, BriannaPhilma, VitalPirko, PhyllisRhoads, DanRuiz, IvanRuss, MichaelSalvator, MatthewSaroukos, AnthonySchrack, LeslieShepard, NikkiWilliams-Lewis, NicoleWoods, DarrylYoung, AmyWhen is the last time you heard from your agent? How did you hear about us? Phone:Email Address:* Preferred Method of Contact Phone Email Text Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Family MemberD/O/BHeight/WeightOccupationTobacco (Y/N) Do you have current health insurance? Y N If yes, current:DeductibleColumn Co-PayMonthly PremiumAnnual PremiumWhat is most important to you about health insurance? Monthly Premium Low Co-Pay/Deductible Choice of Doctor Annual Premium What health related issues have you/family had in past 5 years?What medications are you/family currently taking?Are you interested in dental insurance too?What would happen if you were to become disabled or pass away suddenly, would your family be protected? IF not are you interested in a Disability or Life Insurance quote as well?Affordable Care Act Questions:How many total people are in your household including dependent children?What was your gross annual income last year? (Note this is to see if you qualify for government subsidies for your health insurance premium)Notes:We want to let you know how we get paid. We get paid two ways; one is a commission that comes from the company directly, not from your pocket, and the other is by referrals from our clients. So if we do a good job for you, we hope that you would consider to refer us to your friends, family & co-workers.PhoneThis field is for validation purposes and should be left unchanged.