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ACA Client Intake Information - Medical Professional Discussing ACA With Older Couple

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ACA Client Intake Information – Marker Insurance

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Name

First Name Last Name

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First Name

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Last Name

First Name

Last Name

Date of Birth

Social Security

Address

Street

City

State

Zip Code

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Address

City State ZIP Code

Email Address

Mobile Number

What Health Insurance do you currently have and why are you looking to make a change?

When do you need the new policy to be effective?

Adjusted Gross Income

Your best estimate of household income for this current calendar year. This is necessary to calculate the most accurate premium since the ACA subsidies are based upon your AGI.

Are there doctors or hospitals that you need in the provider network?

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Are you taking any prescription drugs that you want to be covered by the plan?

Please provide names and dates of birth for all family members to be covered on this policy.

Family Member 1

Name 1

First Name Last Name

Date of Birth 1

Social Security 1

Family Member 2

Name 2

First Name Last Name

Date of Birth 2

Social Security 2

Family Member 3

Name 3

First Name Last Name

Date of Birth 3

Social Security 3

Family Member 4

Name 4

First Name Last Name

Date of Birth 4

Social Security 4

I would like information about:

Health Insurance

Vision Insurance

Long Term Care Insurance

Dental Insurance

Life Insurance

Cancer Policy

Annuity

Other

Referred by

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