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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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Layout
Application
Renewal
New 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
Layout (copy)
Email
Phone
Layout (copy) (copy)
Yearly Adjusted Gross Income (after deductions)
Any additional income?
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Employer
Employer's Phone
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Adding Spouse
No
Yes
Spouse
Spouse's Full Name
*
Spouse's Date of Birth
*
Spouse's Social Security Number
*
Spouse's Email
*
Spouse's Number
*
Spouse's Employer
Spouse's Employer Number
Adjusted Gross Income (after deductions)
Child One
No
Yes
Child One Options
Does this Child Need Coverage?
No
Yes
Gender
---
Male
Female
Child's Full Name
*
Child's Social Security Number
*
Child's Date of Birth
*
Income
Child Two
No
Yes
Child Two Options
Does this Child Need Coverage? --
No
Yes
Gender --
---
Male
Female
Child's Full Name --
*
Child's Social Security Number --
*
Child's Date of Birth --
*
Income --
Child Three
No
Yes
Child Three Options
Does this Child Need Coverage? ---
No
Yes
Gender ---
---
Male
Female
Child's Full Name ---
*
Child's Social Security Number ---
*
Child's Date of Birth ---
*
Income ---
Child Four
No
Yes
Child Four Options
Does this Child Need Coverage? ----
No
Yes
Gender ----
---
Male
Female
Child's Full Name ----
*
Child's Social Security Number ----
*
Child's Date of Birth ----
*
Income ----
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.
Submit