Complete Application Name * First Name Last Name Email * Birthday MM DD YYYY Phone (###) ### #### Gender Male Female Address Zipcode Tobacco User? Yes No Marital Status Married Single Divorced Widow What is your current working status? Employed Unemployed Disabled - Receiving Social Security What is your estimated total annual income for 2023? $ If making less than $1100 per month, I agree I am looking for a job making more than $1100 per month. Yes, I am looking for increased income sources to get my income above $1100 per month No, I am not looking for income sources to increase my income over $1100 per month. Do you claim dependents on your taxes? 0 1 2 3 4 5 or more Primary Doctor's Full Name Please include the city doctor is located Are you seeing a specialist doctor? Please include the city doctor is located. CONFIRMATION - FINAL STEPS CONFIRMATION: By checking this box, you attest that all information is true and correct to the best of your knowledge. You are giving Schopmeyer Insurance the permission to finish processing your Health Insurance Marketplace application. You also agree to Schopmeyer Insurance becoming your Agent of Record and contacting you to discuss your three best options to save money and maximize your benefits. Social Security Number Typing your social security number will serve as your signature on this form. Thank you for applying for health insurance with Schopmeyer Insurance. A licensed sales agent will reach out in the next 36 hours to answer your questions and provide your best three options for saving money and maximize your benefits.
