Tonya LeGrande & Associates
2023 Health Insurance Pre-Appt. Form
PRIMARY CONTACT INFORMATION
Primary Contact Name
*
Gender
*
Marital Status:
*
Single
Single Parent
Married
Address
*
Address
Street Address Line 2
City
State
Zip Code
Home Phone
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Work Phone Number:
Format: (000) 000-0000.
Cell Phone:
*
Format: (000) 000-0000.
HOUSEHOLD MEMBERS:
Please list
all
members who will be claimed on your 2023 Taxes. You will need to list yourself as well as those you will be claiming on your 2023 taxes. The Health Insurance subsidy application is based on how you file your 2023 taxes – each person you claim will need to be listed.
You will all need to complete their
gender
,
Birthdate
,
Social Security Number
,
Tobacco use
, confirm you will claim them on your taxes along with if they need insurance coverage.
Household Member #1:
Name:
*
Gender:
*
Please Select
Male
Female
Birthdate:
*
-
Month
-
Day
Year
Date
Social Security Number:
*
Tobacco User:
*
YES
NO
Will you be claimed on 2023 taxes (if head of household it is still "YES")
*
YES
NO
Need Insurance Coverage for 2023:
YES
NO
Household Member #2:
Name:
Gender:
Please Select
Male
Female
Birthdate:
-
Month
-
Day
Year
Date
Social Security Number:
Tobacco User:
Yes
No
Will you be claimed on 2023 taxes:
Yes
No
Needs insurance Coverage for 2023:
Yes
No
Household Member #3:
Name:
Gender
Please Select
Male
Female
Birthdate:
-
Month
-
Day
Year
Date
Social Security Number:
Tobacco User:
Yes
No
Will you be claimed on 2023 taxes:
Yes
No
Needs insurance Coverage for 2023:
Yes
No
Household Member #4:
Name:
Gender:
Please Select
Male
Female
Birthdate:
-
Month
-
Day
Year
Date
Social Security Number:
Tobacco User:
Yes
No
Will you be claimed on 2023 taxes:
Yes
No
Needs insurance Coverage for 2023:
Yes
No
Household Member #5:
Name:
Gender:
Please Select
Male
Female
Birthdate:
-
Month
-
Day
Year
Date
Social Security Number:
Tobacco User:
Yes
No
Will you be claimed on 2023 taxes:
Yes
No
Needs insurance Coverage for 2023:
Yes
No
Household Member #6:
Name:
Gender:
Please Select
Male
Female
Birthdate:
-
Month
-
Day
Year
Date
Social Security Number:
Tobacco User:
Yes
No
Will you be claimed on 2023 taxes:
Yes
No
Needs insurance Coverage for 2023:
Yes
No
Household Member #7:
Name:
Gender:
Please Select
Male
Female
Birthdate:
-
Month
-
Day
Year
Date
Social Security Number:
Tobacco User:
Yes
No
Will you be claimed on 2023 taxes:
Yes
No
Needs insurance Coverage for 2023:
Yes
No
HOUSEHOLD INCOME:
The income portion of the form is very important. Please list each person in the household under “Applicant” who will be receiving income in 2023. We will need their monthly income and annual income (take the monthly income x 12). Include the source of the income – employer name, address and phone number are essential.
Please make sure each annual income column adds up correctly and is the sum of the "2023 Annual Household Income".
Please DO NOT round up the annual income to a higher number than what your total income adds up to.
This is very difficult for us to take care of you when the math is done incorrectly.
Number of people in Household (who you will be claiming for 2023 tax year)
*
Income Source #1:
Household member with income:
*
Income Source: Employer name/ Address and Phone or Self-Employed
*
Company name, City, Phone
Monthly Income:
*
Annual Income:
*
Take monthly income and multiply by 12
Income Source #2:
Household Member with Income:
Income Source: Employer name/ Address and Phone or Self-Employed
Company name, City, Phone
Monthly Income:
Annual Income:
Take monthly income and multiply by 12
Income Source #3:
Household Member with Income:
Income Source: Employer name/ Address and Phone or Self-Employed
Company name, City, Phone
Monthly Income:
Annual Income:
Take monthly income and multiply by 12
Income Source #4:
Household Member with Income:
Income Source: Employer name/ Address and Phone or Self-Employed
Company name, City, Phone
Monthly Income:
Annual Income:
Take monthly income and multiply by 12
Income Source #5:
Household Member with Income:
Income Source: Employer name/ Address and Phone or Self-Employed
Company name, City, Phone
Monthly Income:
Annual Income:
Take monthly income and multiply by 12
Income Source #6:
Household Member with Income:
Income Source: Employer name/ Address and Phone or Self-Employed
Company name, City, Phone
Monthly Income:
Annual Income:
Take monthly income and multiply by 12
2023 Annual Household Income:
*
*This is the sum of the annual income under each income source. It must be the grand total and not a rounded number.
Signature
Date
/
Month
/
Day
Year
Date
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