JS-*ACA 2016 Checklist

ACA 2017 Checklist
Compare and Save!

Thank you for the opportunity to help you with your health insurance for 2017. 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 *

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. *

What is your Insurance Premium? *

What is your Current 2015 Premium Discount Tax Credit (Subsidy)? *

Current Plan *

Current Metal Band? *

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 *

Child 2 *

Child 3 *

Child 4 *

Date of Birth (Month/Date/Year) *

Child 2 DOB *

Child 3 DOB *

Child 4 DOB *

Gender *

Spouse's Gender *

Child 1 Gender *

Child 2 Gender *

Child 3 Gender *

Child 4 Gender *

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 2017 Tax Return? *

Estimated 2017 TOTAL INCOME for all Individuals listed above *

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 *

Specialist 3 *

OBGYN Practice Name *

Specialty 1 Practice Name *

Specialist 2 Practice Name *

Specialist 3 Practice Name *

Phone Number *

List any Specialty Prescriptions *

What do you want your insurance to do? *

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

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
9am-5pm & 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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Trout Insurance is a Full Service Independent Insurance Agency Based in WNC.

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ACA 2017 ChecklistCompare and Save!

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ACA 2017 Checklist
Compare and Save!