INDIVIDUAL/FAMILY HEALTH COVERAGE QUOTE (Under age 65 ) ALL INFORMATION IS CONFIDENTIAL !
INSURANCE & ANNUITIES
INCOME PLANNING
EMPLOYEE BENEFIT PLANS
BUSINESS PLANNING
ENTER INFORMATION ABOUT YOUR HOUSEHOLD (California Residents ONLY)
Insurance
Annuities
Retirement Income
Tax Avoidance Strategies
Your INDEPENDENT Resource
949.954.4445
IMPORTANT: ENTER EXPECTED INCOME NUMBERS FOR 2018 (Approx. AGI Line 37 1040 Tax Form)
*ANNUAL INCOME CURRENT MONTHLY INCOME
*i.e MAGI (Definition below) for ALL individuals on your income tax return.
Is group coverage available through your employer ?
Number of dependents (Including you) on your income tax return
Number of adults (Over 18) enrolling in coverage
Number of children (18 & under) enrolling in coverage?
I'M ALSO INTERESTED IN AND READY TO TAKE ACTION ON:
Phone Number (Including area code):
CONTACT INFORMATION
Email Address:
First Name:
Last Name:
Adult 1 AGE
Adult 2 AGE
Adult 3 AGE
Adult 4 AGE
Adult 5 AGE
Home Zip Code:
NOTE: If you use our office to help you shop, we ask that you purchase/enroll for coverage through our office as well . Thank You !
NOTE: If you are NOT looking for PREMIUM ASSISTANCE or MEDI-CAL, you may leave these income fields BLANK
Adult 6 AGE
Adult 7 AGE
Adult 8 AGE
Adult 9 AGE
Adult 10 AGE
Do you currently have a Physician you don't want to lose?
If YES, Full Name:
Phone Number (Including area code):
NOTES and / or list of all medications that are taken by the above children or adults !
IMPORTANT
BE SURE TO CLICK THE SUBMIT BUTTON BELOW AFTER COMPLETING THE ABOVE !
DEFINITION OF MODIFIED ADJUSTED GROSS INCOME (MAGI)
*(MAGI) Modified Adjusted Gross Income, for most taxpayers, is the same as Adjusted Gross Income (AGI) which can be found on:
- Line 4 on Form 1040EZ
- Line 21 on Form 1040A
- Line 37 on Form 1040
Taxpayers who receive Social Security benefits, SSDI, Unemployment Compensation, Retirement or Pension income, Alimony, Rental & Royalty income, earn income living abroad, or earn non-exempt interest should add back that income to AGI to calculate MAGI. Be sure to check with your tax advisor/preparer.
Medi-Cal eligibility will be determined excluding the following types of income: scholarships, awards, or fellowship grants used for education purposes and not for living expenses, and certain American Indian and Alaska Native income derived from distributions, payments, ownership interests, real property usage rights, and student financial assistance.
Zip code 1:
Zip code 2:
What's the advisors name you are working with through our office?
Date you lost, or are losing, coverage?
Do you have a Covered CA Account?
If YES:
Username
Password
(Case Sensitive)
(Case Sensitive)
