2024 ACA Income Form

2024 ACA Income Form

Reminder that this is your current information and you are using numbers for your projected income from January 1, 2024 to December 31, 2024.
Name

First NameLast Name
Please put information in on YOURSELF and all Family Members who will be on 2024 Income Tax Return (please scroll right to complete all fields). This is a secure form, but if you uncomfortable giving us your SS number here, you can give it to us later when we call. If you are a current client, we probably already have it. But, our form is secure, so it really is ok to type it in. :)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What County do you live in?
County
Email
Your current preferred email
Phone Number
Best number to reach you when we call. :)Format: (000) 000-0000.
Is there a good time to call you? :)
Please tell us who your preferred network of doctors is. Many plans have a limited network, so tell us what is most important to you. You can also include the name of your primary doctor if you are inclined. If different family members have differences, please tell us. Example: I would like to go to Aurora doctors and Dr.____ is my PCP. My spouse prefers Ascension doctors and goes to Dr. _____
Prescriptions can be expensive and we want to be sure you can get what you need as affordable as possible. Please let us know if you have something you take that we need to verify will be available to you on your plan. If you don't take any, please use the first line of this section to put in NONE.
Income Information (please scroll right to complete all fields) If you do NOT want us to check for subsidy, please type NO SUBSIDY in the first field below and skip the income questions. But, even if you think you aren't going to get one, we are happy to check to be sure (we expect subsidy levels to be high for next year). ALSO, We need the employer phone number.
Any Deductions to Income (HSA or Traditional IRA Contributions):
Please Add all the Income Amounts and then Subtract any Deduction Amounts. This is your MAGI (Modified Adjusted Gross Income) for Healthcare.gov purposes. PUT THIS NUMBER HERE. This is what we will use to determine your subsidy. YOU MUST HAVE AN ACCURATE NUMBER IN HERE - WE CANNOT DETERMINE YOUR INCOME.
If you do not want us to check for subsidy, Please type NO SUBSIDY in the box.
ANYTHING else you would like to tell us?
Do you have a HRA (Health Retirement Account)? This is different from a Health Savings Account. Having one makes you inelgible for subsidy.
This is for FUN - If you want to make our day, send along a photo of yourself - we would LOVE that! :) Clicking this button will allow your camera on your computer to take your picture or you can upload a fav. :) Completely optional - just a fun surprise!
If, for any reason, you would like to upload any document to us, please do that here. This is not requred, but if you have tax documents that will be helpful then you can put them here.

Cancelof
Please Read this prior to agreeing and signing below.
I understand:
1. Any tax credit received and taken will be reconciled on my income tax return and may potentially be charged back to me on my taxes if I exceed the income qualifications.
2. I must file a joint tax return if I am married.
3. Any changes in income or family structure (ie not claiming a dependent as planned or getting married or divorced, etc.) will affect my tax credit (subsidy) and must be reported/changed on my application asap.
My signature below authorizes Covered Bridge Insurance to complete my enrollment for 2024 health insurance coverage using the information I have provided above.
I will review my application after the enrollment is complete and verify the correct plan has been selected.
Signature
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