Original ACA 2016 Checklist

ACA 2016 Checklist - Compare and Save!

* Indicates required field

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? *

Submit

Trout Insurance Services

Monday-Friday
9:00am - 5:00pm & 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

[email protected]

Trout Insurance is an Independent Insurance Agency Based in WNC.

Privacy Notice Statement | Privacy Policy

“We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or call 1.800.Medicare to get information on all of your options.”

Trout Insurance is an independent authorized agency licensed to sell and promote products from Blue Cross and Blue Shield of North Carolina (Blue Cross NC). The content contained in this site is maintained by Trout Insurance. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. ®, SM Registered marks of the Blue Cross and Blue Shield Association.”