Prepare for your health benefits meeting. 📆

  • Let's get started!

    To find the right health coverage for you, I need a few details.

  • By submitting this form, you agree that a licensed insurance agent from CYA Insurance Agency may contact you by phone, text, or email to discuss your health coverage options. You can unsubscribe at any time.

    CYA Insurance Agency is a licensed, independent insurance agency. We are not affiliated with the government or Medicare.

    🔒 Your information is secure and protected with AWS encryption. It will never be shared without your consent.

    Once your form is submitted, you'll be prompted to schedule a convenient appointment time with one of our agents.

  • Primary Contact

  • Format: (000) 000.0000.
  • Have you used nicotine 4 or more times a week in the past 6 months?*
  • Have you ever been diagnosed with a heart attack, cancer, stroke, diabetes, high blood pressure, or any other medical condition?*

  • Home Address

    Address used on your federal tax return.
  • Do you need to be included on the coverage?*
  • Is your mailing address the same as your home address?*

  • Alternative Mailing Address

  • Household Members

    Your tax information

  • If you are legally "Married", select Yes

    If you are separated, but not divorced, select Yes

    If you are in a common law marriage. As long as you're living together, and your marriage is recognized in the state where you live, or in the state where the common law marriage began, and filing a joint federal tax return, select Yes

    If you are a victim of domestic violence or spousal abandonment. Spousal abandonment means this person can't locate their spouse after making a reasonable attempt to find them, also known as desertion, select No

    If you are widowed, select No

  • Significant Other's Information

    Household, continued
  • Does this person need to be included on the coverage?*
  • *Will you file a joint tax return?*
  • Have you used nicotine 4 or more times a week in the past 6 months?*
  • Has this person ever been diagnosed with a heart attack, cancer, stroke, diabetes, high blood pressure, or any other medical condition?*

  • Children

    Household, continued

  • Child's Information.

    Household, continued

  • Household Income

  • IMPORTANT: 👇

    • Household income pertains to the year in which you carry the insurance.

    • Total household income includes incomes from everybody in the household who’s required to file a tax return.

    • If married, or filing a joint tax return, you must also include your significant other's income, even if they are not applying for coverage.

    • Your tax credit is determined by your household's AGI, adjusted gross income. For more information about how to determine your AGI refer to the IRS website or your tax professional: https://www.irs.gov/filing/adjusted-gross-income#calculateAGI

  • Income Chart

    The federal poverty level (FPL) is a measure of income used to determine eligibility for various government programs, including state benefits and federal tax credits.
  • Image field 156

  • Additional Coverage Questions

  • Has anyone applying for coverage been found not eligible for state (Medicaid) in the past 90 days?*
  • Does anyone applying for coverage have state (Medicaid) coverage that,*

  • List a person's name if they:

    • Were denied state (Medicaid) by the state since the date shown because their income is too high.

    • Were denied state (Medicaid) by the state because their state doesn't cover people with their household type (for example, some states don't cover adults who aren't taking care of children).

    • Are a child denied State (Medicaid) by the state since the date shown because he or she needs to wait a month or more before starting coverage (called the waiting period).

    • Had their (Medicaid) coverage end since the date shown because a change in state rules makes them not eligible for state (Medicaid).

    Don't list a person's name if they:

    • Never applied for State (Medicaid).

    • Were found not eligible for state (Medicaid) by the Marketplace, instead of the state (Medicaid) agency.

    • Were denied or found no longer eligible for state (Medicaid) since the date shown but had changes in income or family size since the denial or loss of coverage (unless the denial was based on immigration status).

    • Applied for state (Medicaid) with the state but haven't received a response.

    • Were denied state (Medicaid) coverage because they didn't turn in paperwork that the state asked for.

  • Existing Coverage Information

  • Does anyone applying for new coverage currently have any existing health coverage?*

  • Before you start this section, gather HRA information.

    You'll need any information about Health Reimbursement Arrangements (HRAs) that the people on this application may have received from an employer. These documents should include start and end dates, and the maximum amount employers will reimburse for health care costs. If you have questions about the HRA, you can also check with the employer.
  • Does anyone applying for coverage have an individual coverage HRA (ICHRA) through their job, or through the job of another person like a spouse or parent?
  • Has anyone applying for coverage been offered an individual coverage HRA (ICHRA) they haven't yet accepted through their job, or through the job of another person, like a spouse or parent?

  • To "accept" an HRA offer, a person must tell the employer that they plan to use the individual coverage HRA. If an HRA is available through an employer, but a person hasn't yet told the employer that they want to sign up for it, they aren't considered to be enrolled in an HRA. In some cases, a person may be able change their mind about enrolling in an HRA they've signed up for, but hasn't started yet. If interested, ask the employer if this is an option. If you have questions about the HRA, check with the employer.

  • Employer Sponsored Coverage

  • Will anyone in the household be offered health coverage through their own job?*

  • Select a person's name if they:
    • Could get health coverage through one or more of their jobs, even if they're not currently enrolled or don't plan to enroll.
    • Could get health coverage through a job, even if the employer's plan isn't currently in Open Enrollment.
    • Don't think they can afford the coverage that's being offered.

    Don't select a person's name if:
    • They aren't offered coverage at all.
    • They don't work enough hours to qualify.
    • Their coverage offer is through someone else's job, like a spouse or parent. We'll ask about these offers later.
    • The only type of coverage available through a job is a Health Reimbursement Arrangement (HRA).
    • However, if a person is offered an HRA and another group health insurance plan, select their name.
    • Their only option for coverage is COBRA continuation coverage or retiree coverage.

  • Affordable coverage

  • In 2026, a job-based health plan is considered "affordable" if your share of the monthly premium in the lowest-cost plan offered by the employer is less than 9.96% of your household income.

    • The lowest-cost plan must also meet the minimum value standard.
      If you’re the employee, affordability is based on only the premium you’d pay for self-only (individual) coverage.
    • For coverage starting January 1, if you’re offered job-based coverage through a household member’s job, affordability is based on the premium amount to cover everyone in the household.
    • Total household income includes incomes from everybody in the household who’s required to file a tax return.

    If the premiums aren’t considered affordable for the employee and the household, they may qualify for savings in a Marketplace plan. But, if the premium is considered affordable for the employee, but not for other members of the household, then only the other household members may qualify for savings.

  • Upcoming Changes

  • Will anyone lose qualifying health coverage in the next 60 days?*
  • Have any of these people been offered an Individual Coverage Health Reimbursement Arrangement (ICHRA) or Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) with a start date between 60 days back and 60 days forward from today's date?*

  • Recent Changes

  • Select any of the life changes that apply to any of the applicants. In some cases this must have taken place within the last 60 days.*

  • Dental and Vision Benefits 🦷 👀

  • Do the adult(s) want to see dental benefits on the quote? 🦷*
  • Do the adult(s) want to see vision benefits on the quote? 👀*
  • If you have children, do they need dental benefits included? 🦷*
  • If you have children, do they need vision benefits included? 👀*

  • Hospitals and Facilities 🏥

  • Select the facility(s) you would use the most.*

  • Doctors

  • Prescriptions

  • Additional Questions

  • In the event of a major accident or illness that prevented you from earning income, how long could you continue to pay your rent, mortgage, utilities, and other essential bills?*
  • Do you have enough life insurance to adequately protect your family?*
  • If we tailor a plan to your specific needs, what monthly budget do you have in mind?*

  • After submission, you'll be prompted to schedule an appointment to discuss the quotes.

  • Should be Empty: