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ACA 2016 Checklist - Compare and Save!
*
Indicates required field
Name
*
First
Last
Zipcode
*
Phone Number
*
Email
*
Current Insurance Co.
*
Blue Cross Clue Shield
United Health Care
Coventry
I don't know
Currently Uninsured
[object Object]
What is your Insurance Premium?
*
This is your Insurance Premium BEFORE the Subsidy (or premium discount tax credit)
What is your Net Premium?
*
Net Premium is your Insurance Premium AFTER your Subsidy.
What is your Deductible?
*
Current Plan
*
Current Metal Band?
*
Bronze
Silver
Gold
Platinum
[object Object]
Enhanced Benefits
*
[object Object]
Your Name
*
Spouse's Name
*
Child 1
*
[object Object]
Child 2
*
Child 3
*
Child 4
*
Date of Birth (Month/Date/Year)
*
Date of Birth (Month/Date/Year)
*
Date of Birth (Month/Date/Year)
*
Child 2 DOB
*
Child 3 DOB
*
[object Object]
Child 4 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
Child 3 Gender
*
Female
Male
Transgender F/M
Transgender M/F
Child 4 Gender
*
Female
Male
Transgender F/M
Transgender M/F
SUBSIDY (PREMIUM TAX CREDIT) INFORMATION
Will all Individuals be listed on the same 2016 Tax Return?
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Yes
No
I don't know
Employer 1
*
Phone Number
*
Employer 2
*
[object Object]
Phone Number
*
Employer 3
*
Phone Number
*
Employer 4
*
Phone Number
*
Estimated 2016 TOTAL INCOME for all Individuals listed above
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Income is GROSS, prior to deductions. Line 37 on your 1040, including full value of social security
Emp 1 - 2016 Income
*
[object Object]
Emp 2 - 2016 Income
*
[object Object]
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
*
[object Object]
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)?
Submit
Coverage
Home & Auto Insurance
ACA-2021
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
Resources
Insurance Partners
Lost Subsidy
2019 Verification-a
Renewal 2020
Privacy Policy
BCBS Online Setup
APTC Income 2021 & Tax Form 1040
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