Bucher Insurance Intake Form

Health Insurance Intake Form
Personal Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Date of Birth*
Social Security Number*
Gender*

MaleFemale
Height*
Weight*

Tell Us About Your Household
Please list Name, Gender, Date of Birth, and Social Security Number for All Household Members and Their Relationship to the Primary Insured: *
Please list Height & Weight for All Household Members: *
Which Household Members Would Like to Apply for Coverage?*

Myself OnlyMe & My SpouseMe & My ChildrenEveryone

Please Tell Us About Your Income
Income Type*
If you are a W-2 employee, please list the name, address, and phone number of your employer. *
Please state the income type for your spouse. *
If your spouse is a W-2 employee, please list the name, address, and phone number of their employer.
What is your total annual household adjusted gross income?*

Please Tell Us About Your Current Coverage
Name of Insurance Company
Monthly Premium
Annual Deductible
Annual Max Out of Pocket
What are some likes/dislikes about your current plan?

What doctors need to be in-network for your plan? Please list name and location. *
What diagnosis, surgeries, and procedures have you had completed in the past?
What medications need to be covered for your plan? *
Is anyone applying for coverage a tobacco user? *

Which ancillary products would you like pricing on? (Dental, Vision, Life, Disability)
Lastly, is there anything additional that we did not ask that would be beneficial to know?
The CMS requires by law that we are required to keep a digital copy of enrollment consent for 10 years.

Health Insurance Enrollment Consent Clause:

I give my permission to Andrew Trusty [insert name of the person or entity who has the consumer’s consent] 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 Marketplace regarding my Marketplace application.

I understand that the Agent will not use or share my personal identifiable information (PII) for any purpose 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 Andrew Trusty.

Lastly, I understand that any misrepresentation of my household income will be reconciled when I file my taxes at the end of the year. I understand that my health insurance agent, Andrew Trusty, is not a tax professional, and any advice pertaining to income and taxes should be given by a tax professional.
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Health Insurance Intake Form

Personal Information

Tell Us About Your Household

Please Tell Us About Your Income

Please Tell Us About Your Current Coverage