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Pre-Qualification
PPACA Subsidy
* Indicates required questions
Name *
First Name
First
Last Name
Last
Email *
Email
Phone # *
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Zip/Postal Code *
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Please select your advisor *
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Anthony Fracchia
India Barrows
Terrell Sartor
Hineth Pettway
LaShawn Boyd
Rob Molloy
Keith Braswell
Jeff Kaminski
Susan Kaplan
Robert Fracchia
2019 Adjusted Gross Income (line 37 of your Federal 1040 Form) *
2019 Adjusted Gross Income (line 37 of your Federal 1040 Form) *
If your income will be higher/lower in 2020 than what you reported in 2019 please detail that amount. *
If your income will be higher/lower in 2020 than what you reported in 2019 please detail that amount. *
Are all individuals legal US citizens/residents? *
Are all individuals legal US citizens/residents? *
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No
Are any family members American Indian or Alaska Natives? *
Are any family members American Indian or Alaska Natives? *
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Are you currently employed working over 30 hours per week? *
Are you currently employed working over 30 hours per week? *
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Are you eligible for group coverage through your employer or spouse’s employer? *
Are you eligible for group coverage through your employer or spouse’s employer? *
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If married, do you file your taxes jointly with your spouse? *
If married, do you file your taxes jointly with your spouse? *
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Current Health Insurance Carrier *
Current Health Insurance Carrier *
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Priority Health
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Current monthly premium
Current monthly premium
Current plan level
Current plan level
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Person 1 - Age *
Person 1 - Age *
Person 1 - Sex *
Person 1 - Sex *
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Person 1 - Uses Tobacco *
Person 1 - Uses Tobacco *
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Person 2 - Age
Person 2 - Age
Person 2 - Sex
Person 2 - Sex
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Person 2 - Uses Tobacco
Person 2 - Uses Tobacco
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Person 3 - Age
Person 3 - Age
Person 3 - Sex
Person 3 - Sex
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Person 3 - Uses Tobacco
Person 3 - Uses Tobacco
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Person 4 - Age
Person 4 - Age
Person 4 - Sex
Person 4 - Sex
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Female
Person 4 - Uses Tobacco
Person 4 - Uses Tobacco
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Person 5 - Age
Person 5 - Age
Person 5 - Sex
Person 5 - Sex
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Male
Female
Person 5 - Uses Tobacco
Person 5 - Uses Tobacco
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Person 6 - Age
Person 6 - Age
Person 6 - Sex
Person 6 - Sex
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Male
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Person 6 - Uses Tobacco
Person 6 - Uses Tobacco
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Person 7 - Age
Person 7 - Age
Person 7 - Sex
Person 7 - Sex
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Male
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Person 7 - Uses Tobacco
Person 7 - Uses Tobacco
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