Name
First Name
Last Name
Individual Health Insurance Questionnaire
Please complete this form and someone will contact you as soon as possible. I give my permission to Doug McCullough Insurance Agency LLC, Douglas McCullough, and/or their staff to provide the following services on behalf of myself, and my entire household if applicable.1. Search for an existing Marketplace application; 2. Completing an application for eligibility and enrollment in a marketplace Qualified Health Plan or government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace Premiums or enrollment in off-exchange insurance products as applicable; 3. Providing ongoing account maintenance and enrollment assistance, as necessary; or 4. Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that Doug McCullough Insurance Agency, and/or their staff will not share my personally identifiable information (PII) and they will ensure that my PII is kept private and safe when collecting, storing, and using my information for the stated purposes above. I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time. I understand that requests must be made in writing, either by sending the request via certified mail to the address below or via email to doug@dmia.us. Agency Contact Information: Doug McCullough 2527 St. Clair River Dr Algonac, MI 48001
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
DOB
Enter Birthday
Have you used tobacco in the last 6 months?
I expect my total household gross income from all sources this year will be...
Enter $ amount here
Enter spouse and dependent information here
Name
DOB
Sex
Smoker
Spouse
Dependent
Dependent
Dependent
Dependent
Dependent
Dependent
Dependent
Primary Doctor Name
Primary Doctor Name
Primary Doctor Name
Specialist Name
Specialist Name
Specialist Name
Enter additional healthcare providers and prescriptions here:
Do any of these situations apply to you
I have had or I will have a change in family size or marital status
I have lost or I will soon lose health insurance
I am looking for a plan during open enrollment
Other
By submitting this form, I acknowledge that I have been informed of the functions and responsibilities that apply to my agents role in the Healthcare Marketplace and off Marketplace coverage. Doug McCullough Insurance Agency LLC (DMIA) and Douglas McCullough has my permission to assist you as outlined above.
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