Individual Health Quote/Subsidy Estimate Request

Request for Individual Health Insurance Quote
and Estimate of Federal Subsidy

Applicant Information

First Name *

Last Name *

Date of Birth *

Email *

Phone *

Zip Code *

NC County of Residence *

Gender *

Any Tobacco Use? *

Do you want to include your spouse on this policy? *

Yes

Spouse's Information

Spouse's First Name *

Spouse's Last Name *

Spouse's Date of Birth *

Any Tobacco Use by Spouse? *

Do you want to include any dependent children on this policy? *

Yes

Dependent Children's Information

Child's Full Name *

Child's Date of Birth *

Child's Tobacco Use *

Child's Gender *

Add Remove

Federal Subsidy Estimate Information

Projected Household Income *

Estimating your income for the tax year
Start by adding up the following items for:
•You and your spouse, if you are married and will file a joint tax return
•Any dependents who make enough money to be required to file a tax return

For each of the following sources, estimate what your income will be in the tax year:
•Wages
•Salaries
•Tips
•Net income from any self-employment or business
(the amount of money you take in from your business minus your business expenses)
•Unemployment compensation
•Social Security payments, including disability --but not Supplemental Security Income (SSI)
•Alimony

Other items to include when estimating your income are: retirement income, investment income, pension income, rental income, and other taxable income such as prizes, awards, and gambling winnings.

DON’T include the following:
•Child support
•Gifts
•Supplemental Security Income (SSI)
•Veterans’ disability payments
•Workers’ compensation
•Proceeds from loans (like student loans, home equity loans, or bank loans)

For more information on reporting your income, see IRS Publication 525.

Number in Household *

Reporting on your household
When counting the number of persons in your household, DO include:
•Yourself
•Your spouse
•Your children living with you, even if they make enough money to file a tax return themselves
•Your unmarried partner who needs health coverage
•Anyone you include on your tax return as a dependent, even if they don’t live with you
•Anyone else under 21 who you take care of and lives with you

DON’T include:
•Your unmarried partner who doesn’t need health coverage and is not your dependent
•Your unmarried partner’s children, if they are not your dependents
•Your parents who live with you, but file their own tax return and are not your dependents
•Other relatives who file their own tax return and are not your dependents

To learn about who qualifies as a dependent, refer to IRS Publication 501.

Do you or any of your family members who will be covered under this policy have access to (even if you are not currently covered under) other health insurance through :

Your spouse's Employer *

Medicare *

Medicaid *

Tricare *

Rhonda Marshall

Account Executive
Life and Health

rmarshall@morrowinsurance.com

Direct Line: 828-694-5190

Schedule an Appointment

Rhonda Marshall is an independent authorized producer licensed to sell and promote products from Blue Cross and Blue Shield of North Carolina (Blue Cross NC). The content contained in this site is maintained by Morrow Insurance Agency, Inc. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association®. Blue Cross and Blue Shield of North Carolina products can be only sold to those residing in North Carolina. ® Registered mark of the Blue Cross and Blue Shield Association

Request for Individual Health Insurance Quoteand Estimate of Federal Subsidy