Healthcare Questionnaire

For Consultative Insurance Partners
Amy Dahl 402-205-8388
amy@cip-omaha.com

Please only fill out what pertains to you and the required fields

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Application

First and Last Name

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Today's Date

Referred By

Date of Birth

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Social Security Number

Address

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Zip Code

County

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Phone

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Yearly Adjusted Gross Income (after deductions)

Any additional income?

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Employer

Employer's Phone

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Adding Spouse

Spouse

Child One

Child One Options

Child Two

Child Two Options

Child Three

Child Three Options

Child Four

Child Four Options

Name of Doctors

Medications that are expensive that you want to be sure are covered.

REASON APPLYING FOR COVERAGE AND/OR LOST COVERAGE DATE:

By signing you have given me all the information above and it is correct to the best of your knowledge, you agree to contact your agent when there are any changes to your income or family status as it could change your subsidy amount or eligibility. You understand that if you miss a payment and your healthcare is cancelled you will have to wait until the next open enrollment to re-enroll and may still be subject to penalties. You agree that you are responsible for assuring the doctors you want are in the network you chose. * To sign use your mouse if on a computer. Then click done. To sign use your finger if using your phone or a touch screen.

Any Additional Information that you would like us to know.

Healthcare Questionnaire

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