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Pre-Qualification
PPACA Subsidy

Fill out our secure pre-qualification PPACA Subsidy form and an expert from Altruis Benefits Consulting will contact you. We will determine if you qualify for a subsidy to help with your insurance plan payments.

* Indicates required questions
Name *
First
Last
Email *
Phone # *
Zip/Postal Code *
-
County *
Please select your advisor *
2019 Adjusted Gross Income (line 37 of your Federal 1040 Form) *
If your income will be higher/lower in 2020 than what you reported in 2019 please detail that amount. *
Are all individuals legal US citizens/residents? *
Are any family members American Indian or Alaska Natives? *
Are you currently employed working over 30 hours per week? *
Are you eligible for group coverage through your employer or spouse’s employer? *
If married, do you file your taxes jointly with your spouse? *
Current Health Insurance Carrier *
Current monthly premium
Current plan level
Person 1 - Age *
Person 1 - Sex *
Person 1 - Uses Tobacco *
Person 2 - Age
Person 2 - Sex
Person 2 - Uses Tobacco
Person 3 - Age
Person 3 - Sex
Person 3 - Uses Tobacco
Person 4 - Age
Person 4 - Sex
Person 4 - Uses Tobacco
Person 5 - Age
Person 5 - Sex
Person 5 - Uses Tobacco
Person 6 - Age
Person 6 - Sex
Person 6 - Uses Tobacco
Person 7 - Age
Person 7 - Sex
Person 7 - Uses Tobacco
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