Contact Information

Your First Name*

Your Last Name*

Your Birthdate* (mm/dd/yyyy)

Email Address*

Phone Number*

Street Address*

City*

State*

Zip Code*

County* (example; Hennepin)

How did you hear about us?

Name of the person who referred you, if applicable

Additional Individuals Needing Coverage

Spouse First Name:

Spouse Last Name:

Spouse Email:

Spouse Birthdate: (mm/dd/yyyy)

First Dependent Name

Birthdate (mm/dd/yyyy)

Second Dependent Name

Birthdate (mm/dd/yyyy)

Third Dependent Name

Birthdate (mm/dd/yyyy)

Fourth Dependent Name

Birthdate (mm/dd/yyyy)

Fifth Dependent Name

Birthdate (mm/dd/yyyy)

Additional Coverage Information

When do you need new coverage to begin?

4/21/2021 ]

Current Coverage

Current Coverage (if other)

Carrier

Deductible

Coinsurance

Premium

Max Out of Pocket

Do you have an HSA plan?

What is your entire household adjusted gross income?

Is anyone taking medications? If so, list the name of the medication, the dosage and if it is brand name or generic.

Does anyone have any medical conditions that require ongoing treatment? If so, explain and include treatment plan.

What is the reason for new coverage?

If other, please explain

Do you have a particular clinic or provider you’d like to keep? Please include their name, clinic and address.

Are you interested in other benefits?

Add

Remove

Any additional comments or questions?

We will follow-up to gather additional info if needed.

Submit

**This will determine if you meet the requirements for a premium subsidy. If you are within 100-400% of the federal poverty guideline, then you may qualify for a subsidy. Refer to the table found here for income levels.

If you qualify and would like to pursue the possibility of a premium subsidy, please fill out this line. If you feel you wouldn’t qualify or would prefer not to take a subsidy then please note that on this line.

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