Health Insurance Intake Form

Note2Self Consulting, Inc

All information is kept in strict confidence.
The premium tax credit – also known as PTC – is a refundable credit that helps eligible individuals and families cover the premiums for their health insurance purchased through the Health Insurance Marketplace.

Your tax credit is based on the income estimate and household information you put on your Marketplace application. If your estimated income falls between 100% and 400% of the federal poverty level for your household size, you qualify for a premium tax credit.
Do you have insurance with ObamaCare
If Yes, please provide your health plan
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
E-mail
Date of Birth
Social Security #
immigration status?

Other
Sex
Job Name
Annual Income
Marital Status
If married, do Spouse need Insurance?
If yes, provide Spouse Information Name, Date of Birth, Social Security, Sex, Job Name, Annual Income
Spouse Immigration status.

Other
Will you claim any dependents on your federal tax return?
If Yes, How Many?
Do your Dependents need Insurance?
If Yes, please provide Denpendents Name, Date of Birth, Social Security, Sex.
Do you have Life Insurance?
If not, would you like me to send you a Quote?
Note to Agent
Healthcare Consumer Consent

I fully understand and give permission for my insurance agent Patricia Harrell NPN#17348992 to assist me with completing an eligibility application, health or life plan selecion, enrollment and ongoing account/enrollment maintenance.
Signature
Date
Should be Empty:

Note2Self Consulting, Inc