Name
First Name
Last Name
Individual Health Insurance Questionnaire
Please complete this form and someone will contact you as soon as possible. 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 and Douglas McCullough has my permission to 1) conduct an online person search, 2) assist with completing an eligibility application, 3) assist with plan selection and enrollment, and 4) assist with ongoing account/enrollment maintenance.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
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 any expensive 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 1) conduct an online person search, 2) assist with completing an eligibility application, 3) assist with plan selection and enrollment, and 4) assist with ongoing account/enrollment maintenance. I further acknowledge that I have received a copy of DMIA Privacy and Security Notice posted at dougmcculloughinsuranceagency.com/privacy. This authorization is continuous unless revoked in writing to DMIA 2527 St. Clair River Dr. Algonac, MI 48001
Esignature-Type Your Name
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