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Individual Health Insurance Questionnaire

We need to gather some information from you for your new health insurance plan. Get started using the form below.

Step 1 of 13

7%

Your Name*
First Last
Email*
Phone*
Date of Birth*
MM slash DD slash YYYY

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Address*
Street Address Address Line 2 City State ZIP Code
County*

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Do you use tobacco?*
- Yes
- No

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Are you married?*
- Yes
- No

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Spouse's Name*
First Last
Spouse's Date of Birth*
MM slash DD slash YYYY
Does your spouse use tobacco?*
- Yes
- No

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Are you or your spouse (if applicable) offered health insurance from an employer?*
- Yes
- No
Of the health insurance plan(s) offered by the employer, is your or your spouse's portion of the premium more than 9.12% of your annual household income for the lowest-cost plan offered?
- Yes
- No
Estimated annual household adjusted gross income?*
All family members included on your tax return. This figure is needed by us to calculate which subsidies you may qualify for.

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Do you have any dependents?*
- Yes
- No
How many?*

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Dependent 1
Name*
First Last
Sex*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY

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Dependent 2
Name*
First Last
Sex*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY

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Dependent 3
Name*
First Last
Sex*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY

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Dependent 4
Name*
First Last
Sex*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY

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Have you recently lost medical coverage (in the past 60 days) or will you lose coverage in the next 60 days?
- Yes
- No

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Consent*

I grant permission to Nulty Insurance to view and use the confidential information provided by me only for these purposes: search for existing marketplace application, assist with completing an application for eligibility & enrollment (including plan selection), provide ongoing account & enrollment assistance, and to assist with inquiries from the marketplace regarding my application. Nulty Insurance will not use or share my personally identifiable information for any other purposes. My consent remains in effect unless revoked, which can be done by emailing my Nulty Insurance agent.
This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.

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Discover The Difference With Nulty Insurance

At Nulty Insurance, we’re more than just an insurance agency; we’re your trusted partner in safeguarding your future against life’s unforeseen events. Proudly serving West Michigan since 1945, we specialize in delivering a wide range of personalized insurance solutions.

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