ACA Information Request for Erin Lukaszewski

Let Us Help!

Open Enrollment for Individual Health Insurance runs from November 1st to January 15th of each year. Looking to enroll or make updates to your current plan? Take a few minutes to fill out and submit the below information so we can save you time and money when it comes to your health coverage.

Name
First Last
Date of Birth
MM slash DD slash YYYY
Dependent Or Household Members
Spouse or Children (Please add all household members whether they are to be insured or not).
Name Birth Date Relationship Need Coverage (Yes/No)
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Email
Primary Care Doctor Name
First Last
Specialists Names
Current Prescriptions
Name Dosage Frequency
Household Income Estimates
Please provide estimated adjusted gross income for the year you are to be insured. If you have multiple sources of income, please list each one separately. Income is for each household member.
Household Income Amount Frequency Paid Income Source

Name	Birth Date	Relationship	Need Coverage (Yes/No)

Name	Dosage	Frequency

Household Income Amount	Frequency Paid	Income Source