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ACA 2016 Checklist
Compare and Save!
Thank you for the opportunity to help you with your health insurance for 2016. Completing this will give us a good start to evaluate:
How you use healthcare
Which doctors you are regularly seeing
An estimate of your premium discount tax credit so we may chose the most effective plan
*
Indicates required field
Name
*
First
Last
Zipcode
*
Phone Number
*
Email
*
Which AIR Restaurant do you work at?
*
Please tell us about your current coverage so we may " Compare and Save. " If you do not have insurance now - please note that under " Current Insurance " dropdown
Current Insurance Co.
*
Blue Cross Clue Shield
United Health Care
Coventry
I don't know
Currently Uninsured
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What is your Insurance Premium?
*
What is your Current 2015 Premium Discount Tax Credit (Subsidy)?
*
Net Premium is your Insurance Premium AFTER your Subsidy. You can find this information in your account at healthcare.gov
Current Plan
*
Current Metal Band?
*
Bronze
Silver
Gold
Platinum
Catastrophic
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Please let us know who will be getting coverage. If you have more than 4 children - please note in the " Comments" box.
Your Name
*
Spouse's Name
*
Child 1
*
[object Object]
Child 2
*
Date of Birth (Month/Date/Year)
*
Date of Birth (Month/Date/Year)
*
Date of Birth (Month/Date/Year)
*
Child 2 DOB
*
Gender
*
Female
Male
Transgender F/M
Transgender M/F
[object Object]
Spouse's Gender
*
Female
Male
Transgender F/M
Transgender M/F
Child 1 Gender
*
Female
Male
Transgender F/M
Transgender M/F
Child 2 Gender
*
Female
Male
Transgender F/M
Transgender M/F
Comments or Additional Information
*
Premium Discount Tax Credits ( Subsidy ) Information
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 2016 Tax Return?
*
Yes
No
I don't know
Estimated 2016 TOTAL INCOME for all Individuals listed above
*
Income is GROSS, prior to deductions. Line 37 on your 1040, including full value of social security
Doctors and How You Use Health Care
All plans with all carriers cover essential benefits.
The biggest difference is IN-Network Medical Providers such as doctors, specialists, & hospitals. We will check your doctors to confirm which insurance companies they work with.
You may also
CLICK HERE
and research via each company's website
PRIMARY PHYSICIAN Name
*
Practice Name
*
Phone Number
*
OBGYN
*
Specialist 1
*
Specialist 2
*
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Specialist 3
*
OBGYN Practice Name
*
[object Object]
Specialty 1 Practice Name
*
Specialist 2 Practice Name
*
[object Object]
Specialist 3 Practice Name
*
Phone Number
*
Phone Number
*
Phone Number
*
Phone Number
*
List any Specialty Prescriptions
*
[object Object]
What do you want your insurance to do?
*
Do you just go to the doctor when you're sick? Do you go to the doctor only for annual checkups? Do you see a doctor/specialist on a regular basis (monthly)?
Thank you for completing this. For 16 years and thousands of folks - 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
We are bound under federal regulations to protect your personal information”
(PII)
Coverage
Home & Auto Insurance
Health Insurance 2021
Medicare
AARP - Hartford
Life Insurance
Income Protection
>
Disability Insurance
Long-Term Care
Critical Illness
Annuities
Dental, Vision, Accident
Health Insurance 2020
Employee Benefits
Business Owners
>
Employee Benefits
Group Health Insurance
Commercial Property & Liability
Business Overhead Expense Disability
Disability for Business Owners
Critical Illness
Short Term Health
About Us
Our Story
Dave Trout
>
DT Landing
Jessica Cody
>
JC Landing
Jeremy Sheridan
>
JS Landing
Jennifer Trout
Jan Trout
John Phillips
>
JP Landing
Steve Dillingham
Reviews
Client Center
Client Center
Resources
>
Insurance Partners
Lost Subsidy
2019 Verification-a
Renewal 2020
Privacy Policy
BCBS Online Setup
APTC Income 2021 & Tax Form 1040
Asheville Homesharing
American Rescue Plan
ARP Facts CMS
ARP Unemployment
ARP 2020 Excess Premium Subsidy
Community
Music on Main
Manna Fundraiser
Western Women's Business Center Conference
Mural on Main Street
Expanded Team- Next Generation
Back to School
Weaverology
Blog
Contact Us