AEP Health Renewal Quote Sheet

Name of Primary Household Contact*

First NameLast Name

Your name (if different than above)

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Birthdate

Date

Email*

example@example.com

Phone Number

Area CodePhone Number

Text Message Authorization: (Please choose one option)

Yes, I authorize ISC agents/staff to send text messages to me on any of my mobile phone numbers.I authorize ISC to send texts only to a specific number.No, I do not authorize ISC agents/staff to send text messages. (NOT RECOMMENDED)

Which phone number(s) can ISC text to:

What county do you live in? (Example: Brown, Outagamie, Kewaunee, etc.)*

In the past 6 months, have you used tobacco in any form?*

YesNo

Do you currently receive a premium subsidy credit?*

YesNo

On March 11, 2021 the American Rescue Plan of 2021 was signed into law. Individuals and families may be eligible for premium tax credits for plan year 2025, with no one paying more than 9.12% of their household income towards the cost of the plan. Would you like to provide us with your income information to see if you will qualify for a premium subsidy?*

Yes, I will provide my income.No, I will not provide my income.

Will you be offered a group plan from your employer next year?*

YesNo

Will you be offered a health reimbursement arrangement next year? (This is money from your employer to reimburse medical expenses, like monthly premiums and out-of-pocket costs like copayments and deductibles.)*

YesNo

YOUR 2025 Estimated Annual Modified Adjusted Gross Income/Wages/Tips (before taxes). If you are married, we will ask for your spouse's income separately.*

	What will be the source of your income (Employer Name, Self Employed - type of work, Social Security, Retirement, etc.)	How often are you receiving this income (hr, weekly, monthly, annually) If hourly, please include how many hours weekly	What is the income amount you receive before taxes ($)
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Marital Status?*

SingleMarried

Spouse's Name*

First NameLast Name

Spouse's Birthdate

Date

In the past 6 months, has your spouse used tobacco in any form?*

YesNo

SPOUSE'S 2025 Estimated Annual Modified Adjusted Gross Income/Wages/Tips (before taxes).*

	What will be the source of your income (Employer Name, Self Employed - type of work, Social Security, Retirement, etc.)	How often are you receiving this income (hr, weekly, monthly, annually) If hourly, please include how many hours weekly	What is the income amount you receive before taxes ($)
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Does your spouse need to be covered under your plan?*

Yes, my spouse also NEEDS coverage under my plan.No, my spouse DOES NOT need coverage under my plan.

Will there be anyone else in your household next year (children, stepchildren)?*

YesNo

	Child's Legal Name	Birthdate	Relationship	Sex (M/F)	Do they need coverage?	Are you claiming them on your 2025 taxes?
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What provider/network group(s) do you prefer?*

Are you concerned about coverage on specific medication(s)?*

YesNo

	RX Name: Please copy ALL details from the package, including HCL, SR, ER, immediate release, etc. EX: Tramadol HCL CAP ER	Dosage (strength) (ml, mg, etc.) EX: 300 MG capsules	30 day refill: quantity filled every 30 days	90 day refill: quantity filled every 90 days EX: 185 capsules every 3 months	Name of Retail Pharmacy or Mail Order?
1
2
3
4
5
6

Are you or anyone listed on the application offered health coverage from a job? Check yes even if you don't accept the coverage?*

YesNo

If yes, explain:

How do you prefer we contact you with your quotes?*

E-mail me my optionsPhone CallVirtualOther

Do you agree to allow the Marketplace to use income data, including information from tax returns, for the next 5 years?*

Yes, I agreeNo (Selecting no may impact your ability to get help paying for coverage at renewal.)

Do you have any comments, questions, or concerns that you would like your agent to be aware of?

Medicaid

If anyone on this application is eligible for Medicaid:

I'm giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I'm also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.
If any child on this application has a parent living outside of the home, I know I'll be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell Medicaid and I may not have to cooperate.
I'm signing this application under penalty of perjury, which means I've provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.
I know that I must tell the Health Insurance Marketplace within 30 days if anything changes (and is different than) what I wrote on this application. I can visit HealthCare.gov or call 1-800-318-2596 to report any changes. I understand that a change in my information could affect my eligibility as well as eligibility for member(s) of my household.
I know that under federal law, discrimination isn't permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file.
I know that information on this form will be used only to determine eligibility for health coverage, help paying for coverage (if requested), and for lawful purposes of the Marketplace and programs that help pay for coverage. We need this information to check your eligibility for help paying for health coverage if you choose to apply. We'll check your answers using information in our electronic databases and databases from the Internal Revenue Services (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn't match, we may ask you to send us proof.

What should I do if I think my eligibility results are wrong?

If you don't agree with what you qualify for, in many cases, you can ask for an appeal. Please review your eligibility notice to find appeals instructions specific to each person in your household who applies for coverage, including how many days you have to request an appeal. Here's important information to consider when requesting an appeal:

You can have someone request or participate in your appeal if you want to. That person can be a friend, relative, lawyer, or other individual. Or, you can request and participate in your appeal on your own.
If you request an appeal, you may be able to keep your eligibility for coverage while your appeal is pending.
The outcome of an appeal could change the eligibility of other members of your household.

To appeal your Marketplace eligibility results, visit www.HealthCare.gov/marketplace-appeals/. Or call the Marketplace Call Center at 1-800-318-2596. TTY users should call 1-855-889-4325. You can also mail an appeal request form or your own letter requesting an appeal to Health Insurance Marketplace, Dept. of Health and Human Services, 465 Industrial Blvd., London KY 40750-0001. You can appeal eligibility for purchasing health coverage through the Marketplace, enrollment periods, tax credits, cost-sharing reductions, Medicaid, and CHIP, if you were denied these. If you qualify for tax credits or cost-sharing reductions, you can appeal the amount we determined you're eligible for. Depending on your state, you may be able to appeal through the Marketplace or you may have to request an appeal with the state Medicaid or CHIP agency.

Health Checklist

By signing below, you acknowledge the following:

I understand:

•It is my responsibility to review the Summary of Benefits for chosen plan(s).

•There is limited coverage for foreign travel under most policies. Other options
may be available.

•I should not cancel existing coverage until a new policy is officially approved.

•It is my responsibility to cancel prior insurance coverage. A company will not “back date” a cancellation request. I must take steps to make sure the prior policy was canceled, even if a representative of ISC assisted with the cancellation. ISC will NOT be notified of the cancellation of the prior policy.

•I understand that ISC typically does not receive copies of correspondence sent to me by the insurance company or the Marketplace. I will need to call or email my agent if I have questions about the correspondence I have received.

•It is my responsibility to work directly with the insurance company for any billing issues, including initial setup.

•I will need to make all payments directly with the insurance company.

•It is my responsibility to work directly with the insurance company regarding claims-related issues.

•I understand that ISC does not offer every plan available in my area. Currently, we represent 10 organizations which offer 77 products in your area. Please contact Medicare.gov, 1-800-Medicare or your local State Health Insurance Program (SHIP) to get information on all of your options. Health clients: Please contact healthcare.gov or 1-800-318-2596.

•Email and text messages are not secure. I will not send confidential health or financial information via email or text message.

•If my plan has Provider Networks, it is my responsibility to verify that my doctors(s) and or facilities are in my network. If I go to a doctor or facility outside of my network, I understand that it is very likely there may not be coverage.

•I understand, I need to pre-certify for surgery (including some outpatient procedures), hospitalization, and durable medical equipment.

•I understand, it is my responsibility to confirm that my current medications are on my plan’s drug list.

Your Agent's Name*

ACA Consent

By signing below, I, {nameOf} give my permission to {yourAgents} as well as authorized employees of Insurance Service Center - De Pere, LLC to serve as the health insurance agent or broker for myself and my entire household, if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

1. Searching for an existing Marketplace application;

2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums;

3. Providing ongoing account maintenance and enrollment assistance, as necessary; or

4. Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting the agent or broker directly.

Primary Writing Agent:	Brenda Vander Logt
National Producer Number (NPN):	9017507
Phone Number:	920-964-2148
Email Address:	brenda@iscinsurance.com

Name of Agency (if applicable):	Insurance Service Center - De Pere, LLC
Agency NPN:	100195120
Owner of Agency:	Carolyn Baeten and Jessica Dellemann
Phone Number:	920-337-9345
Email Address:	iscmail@iscinsurance.com

Name of Primary Household Contact and/or Authorized Representative:	{nameOf}
Phone Number:	{phoneNumber}
Email Address:	{email}

Primary Writing Agent:	Karen VanDenBusch
National Producer Number (NPN):	6563972
Phone Number:	920-964-2133
Email Address:	karenv@iscinsurance.com

Name of Agency (if applicable):	Insurance Service Center - De Pere, LLC
Agency NPN:	100195120
Owner of Agency:	Carolyn Baeten and Jessica Dellemann
Phone Number:	920-337-9345
Email Address:	iscmail@iscinsurance.com

Name of Primary Household Contact and/or Authorized Representative:	{nameOf}
Phone Number:	{phoneNumber}
Email Address:	{email}

Signature of Primary Household Contact and/or Authorized Representative*

DateTime

Due to confidential information on this form, you will NOT receive an emailed copy. Please be sure to print or save a copy of the form before pressing continue. If you would like a copy of your completed form mailed to you, please let us know.

Office Use Only:

example@example.com