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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Visit: 29 N Main St
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Mail: PO Box 1414
Weaverville, NC 28787

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Fax: 1.888.221.4842

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ACA 2016 Checklist - Compare and Save!

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