DC Insurance Health Coverage Intake

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Date of Birth

Date

5

Best way to contact you

Phone

Email

Text

6

What state do you live in?

7

ZIP code

9

Please list each dependent below (first name, gender, date of birth):Example: - Sarah, Female, 05/12/1985 - Liam, Male, 09/28/2012

10

What are your top priorities when it comes to health coverage?

Monthly Premium

Coverage for big medical events (accidents, surgeries, cancer, etc.)

Telehealth and virtual doctor access

Dental and vision benefits

Prescription coverage

Maternity coverage

Low deductible

Nationwide PPO network

I'm not sure yet

11

Current Insurance SituationWhat type of health insurance do you currently have?

None

12

Who is your current insurance carrier?

13

What do you like or dislike about your current plan?

14

Have you or any family members been diagnosed or treated for any of the following in the past 5 years?

Cancer, Heart disease or heart surgery, Stroke, etc.

Pregnancy (currently or planning)

Hospitalized or had surgery in the past 5 years

15

About what is your household income this year (before taxes)? (This helps me determine if you qualify for ACA savings or if private plans will be a better value.)

Under $30,000

$30,000–$50,000

$50,000–$75,000

$75,000–$100,000

$100,000+

Not sure

16

What’s most important to you in a plan?

I want to avoid big surprise medical bills

I need coverage I can actually use (doctor visits, prescriptions, etc.)

I want to protect my family or dependents

I travel or move around and want nationwide flexibility

I mostly just want coverage for emergencies

I’m not sure — need help understanding what’s possible

17

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