Original ACA 2016 Checklist

ACA 2016 Checklist - Compare and Save!

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Name *

First

Last

Zipcode *

Phone Number *

Email *

Current Insurance Co. *

What is your Insurance Premium? *

What is your Net Premium? *

What is your Deductible? *

Current Plan *

Current Metal Band? *

Enhanced Benefits *

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 *

SUBSIDY (PREMIUM TAX CREDIT) INFORMATION

Will all Individuals be listed on the same 2016 Tax Return? *

Employer 1 *

Phone Number *

Employer 2 *

Phone Number *

Employer 3 *

Phone Number *

Employer 4 *

Phone Number *

Estimated 2016 TOTAL INCOME for all Individuals listed above *

Emp 1 - 2016 Income *

Emp 2 - 2016 Income *

Employer 3 - 2016 Income *

Emp 4 - 2016 Income *

COMPARE & SAVE - All plans with all carriers cover essential benefits. The biggest difference is IN-Network Medical Providers such as doctors, specialists, & hospitals.

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? *

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Trout Insurance Services
Visit: 29 N Main St
Weaverville, NC 28787

Mail: PO Box 1414
Weaverville, NC 28787

Ph: 828.279.4681
Fax: 1-888-221-4842
dtroutinsurance@aol.com

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Privacy Notice Statement | Privacy Policy

Trout Insurance is a full line insurance agency based in WNC. We serve clients in North and South Carolina as well as national companies. Trout Insurance offers life, health, disability, Medicare supplement, Medicare Health Plans, Medicare Prescription Plans, Long term care insurance, Home and Auto insurance for individuals. For businesses we offer group health & benefits, commercial liability, property & worker's compensation as well as plans for business owners.

Dave Trout, Jan Trout, Jessica Cody and Jeremy Sheridan are independent insurance agents with Trout Insurance. Dave Trout specializes in life and disability insurance, Medicare supplement insurance, and commercial business insurance. Jan Trout specializes in Medicare Products. Jessica Cody, specializes in individual health, personal home and auto, small commercial and Medicare. Jeremy Sheridan specialize in Group Health and Employee Benefits, Commercial, Health, Life and Medicare **

ACA 2016 Checklist - Compare and Save!

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