ACA 2020 Checklist

Affordable Care Act 2021 Checklist

Thank you for the opportunity to help with your health insurance for 2021. 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 menu.

Current Insurance Co. *

What is your Insurance Premium? *

What is your Current 2020 Premium Discount Tax Credit (Subsidy)? *

Current Plan *

Current Metal Band? *

Your Agent *

Important - Many New 2021 plans have limited networks of Doctors, Specialists and Hospitals. List your information below. 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 *

Primary Care Doctor *

Comments or Additional Information *

Premium Discount Tax Credits (Subsidy) Information

https://www.kff.org/interactive/subsidy-calculator/
Completing 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 2020 Tax Return? *

Estimated 2020 TOTAL INCOME for all Individuals listed above *

Have you reconciled your Advance Premium Tax Credit or Prior years tax returns for:

2017 *

Yes No I don't know

2018 *

Yes No I don't know

2019 *

Yes No I don't know

List any Specialty Doctors, Treatments or Prescriptions *

What do you want your insurance to do? *

Thank you for completing this form. For 20 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
8:30am-6pm & 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 2021 Checklist
Compare and Save!

Affordable Care Act 2021 Checklist

Subscribe!

ACA 2021 ChecklistCompare and Save!

Affordable Care Act 2021 Checklist

Subscribe!

ACA 2021 Checklist
Compare and Save!