JFS Open Enrollment 2021 Screening

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Please answer all questions the best you can. Once submitted, an Assister will reach out to you to schedule an appointment.

If you need help determining the answer to any of the questions below, please reach out to us at 973-250-6665 or email gcnj@jfsclifton.org

Email *

What is your legal first and last name? *

What is your home address? *

What is your city, state and zip code? *

Can we contact you through e-mail? *

Yes

I would prefer to be called

Best Contact Number *

Preferred E-mail Address *

What is your family size? *

Count everyone who will appear on your tax return (Form 1040)

Who Needs Insurance (Check all that apply)? *

You

Your Spouse

Your Children

Other:

Required

What is your date of birth? *

YYYY

What is your spouse's date of birth?

YYYY

Is anyone in your family pregnant? *

Yes

Did you file a tax return last year? *

Yes

How much income will your family receive in 2021 (estimated)? *

Enter the amount of income that anyone on your tax return is expected to receive in 2021. For those that receive income from an employer, enter the amount expected to receive before taxes. For those that are self-employed or receive rental income, enter the estimated net income (after expenses). For those who are self-employed, we recommend speaking to your accountant to calculate this number. Please note that this projected amount can change throughout the year. The number you are providing is an estimate.

What is your current medical insurance? *

List all the insurance providers your family is currently covered by, including Medicaid in any State, Commercial, or Private Insurance. Write "uninsured" if you do not have insurance.

Did you ever receive insurance through The Marketplace? *

I am currently receiving insurance through The Marketplace

I previously received insurance through The Marketplace

Do you or your spouse's employer offer the option of medical insurance? Enter yes whether or not you would consider enrolling in the plan, and regardless of the price. DO NOT ANSWER THIS QUESTION UNTIL YOU ARE CERTAIN THAT YOU KNOW THE ANSWER. *

Yes

If an employer does give you the option of purchasing insurance, does the employer also offer an option for the spouse to join the plan? Enter yes whether or not you would consider enrolling in the plan, and regardless of the price. DO NOT ANSWER THIS QUESTION UNTIL YOU ARE CERTAIN THAT YOU KNOW THE ANSWER. *

Yes

Not Applicable

If an employer does give you the option of purchasing insurance, enter the amount it would cost the EMPLOYEE to buy the CHEAPEST possible EMPLOYEE only plan. DO NOT ANSWER THIS QUESTION UNTIL YOU ARE CERTAIN THAT YOU KNOW THE ANSWER.

Please enter a monthly dollar amount

Additional notes for the JFS Case Manager

Please use this space to write any additional information that will help the Case Worker understand your situation.

By checking this box, I authorize JFS Navigators to maintain or store my Personally Identifiable Information (PII) to ensure JFS’s continuous ability to provide quality services. I understand that I do not have to give JFS more information than I choose to provide. *

I authorize JFS Navigators to maintain or store my Personally Identifiable Information (PII) to ensure JFS’s continuous ability to provide quality services. I understand that I do not have to give JFS more information than I choose to provide.

I do not authorize JFS Navigators to maintain or store my Personally Identifiable Information (PII) to ensure JFS’s continuous ability to provide quality services.

Required

Today's Date *

Please use this space to write any additional information that will help the Case Worker understand your situation.

YYYY

Send me a copy of my responses.

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