Part 2: Your Information

Your Name

Date of Birth

First Name

Last Name

Date of Birth

Phone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

City

State

Zip Code

Tobacco usage?

Yes

Native American or Alaskan Native?

Yes

Part 3: Family Information

*Skip any questions that do not apply to you.

Spouse

Your Spouse's Name

Date of Birth

First Name

Last Name

Date of Birth

Phone Number

example@example.com

Tobacco usage?

Yes

Native American or Alaskan Native?

Yes

Dependents

If you have more than 4 dependents, you can add their info to the "Additional Information" section at the end of this questionnaire.

Dependent #1

Date of Birth

First Name

Last Name

Date of Birth

Dependent #2

Date of Birth

First Name

Last Name

Date of Birth

Dependent #3

Date of Birth

First Name

Last Name

Date of Birth

Dependent #4

Date of Birth

First Name

Last Name

Date of Birth

Do any dependents use tobacco products? If yes, please list them by name:

Are any dependents Native American/Alaskan Native? If yes, please list them by name here:

Part 6: ACA Agent Consent Form

Disclosure and Consent Agreement:

I give my permission to Bethany Boos Insurance, LLC/Bethany Boos (Agent) 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 both on the Federally Facilitated Marketplace and off the 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:

Searching for an existing Marketplace application;
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;
Providing ongoing account maintenance and enrollment assistance, as necessary;
or Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes 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 consent, and I may revoke or modify my consent at any time by contacting the Agent in writing (i.e. letter or email).

Name of Primary Household Contact*

Date*

First Name

Last Name

Date*

Date

example@example.com

Health Insurance Questionnaire

Part 1: General Information

How did you hear about Health And Legacy Organization?

Who are you looking to cover?

What is most important to you regarding your health insurance plan?

Do you currently have health insurance?

Have you recently, or will you soon be losing your insurance coverage?

If yes, when was/will be the last day of coverage?

What kind of health insurance coverage do you/did you have?

Part 2: Your Information

Your Name

Date of Birth

Date of Birth

Phone Number

Email

Address

Tobacco usage?

Native American or Alaskan Native?

Part 3: Family Information

Spouse

Your Spouse's Name

Date of Birth

Date of Birth

Tobacco usage?

Native American or Alaskan Native?

Dependents

Dependent #1

Date of Birth

Date of Birth

Dependent #2

Date of Birth

Date of Birth

Dependent #3

Date of Birth

Date of Birth

Dependent #4

Date of Birth

Date of Birth

Do any dependents use tobacco products? If yes, please list them by name:

Are any dependents Native American/Alaskan Native? If yes, please list them by name here:

Part 4: Doctors and Prescription Medications

Doctors and Other Medical Providers (include Dentist and Eye Doctor if wanting dental/vision)

Prescription Drugs (include drug name, dosage, pill vs. capsule, etc)

Preferred Pharmacy

Part 5: Employment & Financial Information

Did you complete your taxes for the previous year?

If married, how do you file taxes?

Total number of household members including yourself? (Tax household)

Will you be claimed by anyone as a dependent for tax purposes?

Your Employer Name & Phone

Your Annual Income

Does your employer OFFER health insurance to you/your family?

Your Spouse's Employer Name & Phone

Your Spouse's Annual Income

Does your spouse's employer OFFER health insurance to you/your family?

Part 6: ACA Agent Consent Form

Name of Primary Household Contact*

Date*

Date*