TO: ALL EMPLOYEES (Full time and Part Time)
SUBJECT: 2023 Health Insurance Questionnaire
Please complete the items below and click the SUBMIT button to
forward to our agent to determine your health insurance eligibility
and options. Your information will remain private and will be used
exclusively for the purpose of determining your eligibility for
premium subsidies, and the benefit options available to you.
This is NOT an enrollment form. When received, our broker will
email you an outline of your options, and information about how
to enroll for coverage.
NAME:
COUNTY OF RESIDENCE:
EMAIL ADDRESS:
PHONE:
YOUR AGE:
YOUR GENDER:
USE TOBACCO?
EXPECTED INCOME IN 2023?
MARRIED OR SINGLE?
IF MARRIED,
AGE OF SPOUSE:
SPOUSE'S EXPECTED INCOME IN 2023:
COVERAGE NEEDED FOR SPOUSE?
USE TOBACCO PRODUCTS?
DOES SPOUSE HAVE CVG AVAILABLE
THRU EMPLOYER?
AGES OF DEPENDENT CHILDREN:
DO YOU WISH TO COVER YOUR CHILDREN?
COMMENTS:
www.ivysalonbenefits.com
