Who Will Be Covered?

Your First Name: (required)

Your Last Name: (required)

Your Birthdate: (required, mm/dd/yyyy)

Spouse First Name:

Spouse Last Name:

Spouse Birthdate: (mm/dd/yyyy)

Dependent Names

Dependent Birthdates (mm/dd/yyyy)

Additional Information:

When do you need new coverage to begin?

10/18/2017 ]

Do you have the option for employer-sponsored coverage?

Email Address: (required)

Phone Number: (required)

Street Address: (required)

City: (required)

State: (required)

Zip Code: (required)

County: (required)

**If seeking financial assistance through MNSure: What is your estimated household modified adjusted gross income this year? (If similar to previous year refer to Line 4 on Form 1040EZ, Line 21 on Form 1040A, or Line 37 on Form 1040)

How did you hear about us?

Name:

Any additional comments or questions?

1) Are you self-employed or a small business owner? ----- If yes, please answer questions a, b, c.

a) How is your business setup as an entity? Sole Proprietorship, LLC, Corporation, Partnership...

b) How many employees work for the business a minimum of 20 hours or more on average/per week?

c) If you have other employees, would you like to offer benefits? If so, Minimum Employer Contribution of 50% of Premium is Required.

We will follow-up to gather additional info if needed.

Is anyone taking medications? If so, list the name of the medication, the dosage and if it is brand name or generic.

Does anyone have any medical conditions that require ongoing treatment? If so, explain and include treatment plan.

Does anyone use tobacco products (on average more than 4x per week in the past 6 months)? If so, please indicate which applicant and estimated use.

If you have coverage currently, what is your deductible/coinsurance amount, current premium amount, renewal premium amount (if applicable) carrier name and group ID #?

What is the reason for new coverage? Ie. Loss of group coverage, life change, moving to a new service area, shopping to lower rates etc..."

Do you have a particular clinic or provider you’d like to keep? Please include their name, clinic and address.

Submit!

**This will determine if you meet the requirements for a premium subsidy. If you are within 100-400% of the federal poverty guideline, then you may qualify for a subsidy. Refer to the table found here for income levels.

If you qualify and would like to pursue the possibility of a premium subsidy, please fill out this line. If you feel you wouldn’t qualify or would prefer not to take a subsidy then please note that on this line.

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