ACA 2019 Checklist-JC

Thank you for the opportunity to help you with your health insurance for 2019. Completing this form will provide us with an estimate of your premium discount tax credit so we can help you select the most effective plan.

* Indicates required field

Name *

First

Last

Zipcode *

Phone Number *

Email *

County *

Please tell us about your current coverage so we may "Compare and Save." If you don't have insurance now - please select that option under "Current Insurance Co." dropdown

Current Insurance Co. *

What is your Insurance Premium? *

What is your Current 2018 Premium Discount Tax Credit (Subsidy)? *

Current Plan *

Current Metal Band? *

Please let us know who will be getting coverage. If you have more than 3 children - please provide additional info for them in the "Comments" box.

Your Name *

Your Date of Birth (M/D/Y) *

Gender *

Spouse's Name *

Spouse's Date of Birth (M/D/Y) *

Spouse's Gender *

Child 1 Name *

Child 1 Date of Birth (M/D/Y) *

Child 1 Gender *

Child 2 Name *

Child 2 Date of Birth (M/D/Y) *

Child 2 Gender *

Child 3 Name *

Child 3 Date of Birth (M/D/Y) *

Child 3 Gender *

Comments or Additional Information *

Premium Discount Tax Credits ( Subsidy ) Information

www.bcbsnc.com/subsidyCompleting this will allow us to estimate your Premium Discount. You may also get an estimate HERE

HEALTH INSURANCE MARKETPLACE CALCULATOR

Will all Individuals be listed on the same 2019 Tax Return? *

Estimated 2019 TOTAL INCOME for all Individuals listed above *

List any Specialty Doctors, Treatments or Prescriptions *

What do you want your insurance to do? *

Thank you for completing this form. For 17 years we have worked hard to live up to our motto of " More Value for Your Insurance Dollar$ " We appreciate the opportunity to work with you.

Submit

Disclaimer: We verify your doctor's status by the insurance companies “in network provider list” as published on their website. It is advisable to check with your doctors as to their arrangements with the insurance companies.

We are bound under federal regulations to protect your personal information” (PII)

Trout Insurance Services

Monday-Friday
9:00am-5:00pm & by Appointment

Visit: 29 N Main St
Weaverville, NC 28787

Mail: PO Box 1414
Weaverville, NC 28787

Ph: 828.279.4681

Fax: 1.888.221.4842

contact@troutinsurance.com

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ACA 2019 Checklist
Compare and Save!

Subscribe!

ACA 2019 ChecklistCompare and Save!

Subscribe!

ACA 2019 Checklist
Compare and Save!