Health Insurance Quote
Please read each question carefully. Everything is part of the quoting process which helps determine if you're eligible for a subsidy and how much.  Please provide your answers in the field below the question. When finished, scroll to the bottom and hit the submit button.
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Primary Contact
1. Contact Name 
2. Email (need to send quote somewhere)
3. Phone Number (optional)
*
Zip Code *
County you reside (Not Country) *
HouesholdYou must file taxes jointly for a subsidy and anyone you claim (regardless of needing coverage) is included in the household. 
1. How many in household? 
2. How many need coverage? 
3. If someone does not need coverage, explain why. IE: Spouse is on Medicare, Ex Spouse Covers Child (if you claim a child, include them even if they don't need coverage).
*
Income
1. What is the adjusted gross income for the household info above? Include the income on anyone who you file taxes joinlty with or claim as a dependent regardless of needing coverage.  IE: Your 16 year old son who works at a grocery store would be counted as income or your spouse on Medicare (whether they need coverage or not).  
2. The Heath Insurance Marketplace uses an income figure called Modified Adjusted Gross Income (MAGI) for the current year to determine the programs and savings you qualify for. For most people, it's identical or very close to Adjusted Gross Income (AGI). MAGI is not a line on your federal tax return (seek tax advice if you do not know).
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In the sections below, only enter family members needing coverage.
In the section below, make sure to include only individuals that NEED coverage. In the question above, it asks how many in household and how many need coverage. If your spouse is on Medicare, I need to know they are in the household, but I don't need their info below.  Only those that need coverage are included below.   Tobacco use is the use of any tobacco product, including cigarettes, cigars, chewing tobacco, snuff, and pipe tobacco, four or more times a week within the past 6 months.
Current Coverage
1. Are you currently insured?  
2. What type of policy is it?  If currently insured, when does it end? If no, when did you last have coverage?
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Primary Applicant: 
Name 
Birthdate
Gender 
Tobacco use
*
Spouse:
Name 
Birthdate
Gender 
Tobacco use
Children/Dependents: (List All Here)
Name 
Birthdate
Gender 
Tobacco use
Doctor or Hospital Network: (Full Name, Location & Specialty for Each)
Prescription Medications: (list all)
Name
Dosage
Frequency
Thank You
Who referred you or how did you find me? If you have any additional info you think would help, please supply here.
*
Submit
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