Individual & Family Plan Questionnaire

Individual & Family Plan Questionnaire
Contact information

Please complete all fields below. This information will be used to prepare accurate health plan quotes.
Name

First NameLast Name
Best Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best Email
example@example.com
Preferred Contact Method
Address

Street Address

Street Address Line 2

CityState

Zip Code
What county do you live in?
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you seeking coverage?
Gender
Tobacco User
Household Information

Household includes the people who are part of your tax return, such as your spouse and anyone you claim as a dependent.

Household Member Information

Household includes the people who are part of your tax return, such as your spouse and anyone you claim as a dependent.
Name

First NameLast Name
This household member is my..
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are they seeking coverage?
Gender
Tobacco User

Household Member #2

Household includes the people who are part of your tax return, such as your spouse and anyone you claim as a dependent.
Name

First NameLast Name
This household member is my..
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are they seeking coverage?
Gender
Tobacco User

Household Member #3

Household includes the people who are part of your tax return, such as your spouse and anyone you claim as a dependent.
Name

First NameLast Name
This household member is my..
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are they seeking coverage?
Gender
Tobacco User

Household Member #4

Household includes the people who are part of your tax return, such as your spouse and anyone you claim as a dependent.
Name

First NameLast Name
This household member is my..
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are they seeking coverage?
Gender
Tobacco User

Household Member #5

Household includes the people who are part of your tax return, such as your spouse and anyone you claim as a dependent.
Name

First NameLast Name
This household member is my..
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are they seeking coverage?
Gender
Tobacco User

Household Member #6

Household includes the people who are part of your tax return, such as your spouse and anyone you claim as a dependent.
Name

First NameLast Name
This household member is my..
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are they seeking coverage?
Gender
Tobacco User

Household Income

If you don’t provide income information, you’ll receive full-price quotes without potential premium reductions.
Provide your projected annual household income for the year you need coverage. Your income may affect your premiums and coverage options.

Example: For coverage starting November 2026, provide your household’s projected income for January–December 2026.

For more information visit: Household Income / MNsure or Income Level Guidelines for Financial Help
Projected Modified Adjusted Gross Income

Providers/Clinics

Doctors, specialists, hospitals, or healthcare facilities you prefer to use.
Provider's Name
Clinic/Hospital Name
Location of Medical Facility
City
# of Visits per Year

Providers/Clinics #2

Doctors, specialists, hospitals, or healthcare facilities you prefer to use.
Provider's Name
Clinic/Hospital Name
Location of Medical Facility
City
# of Visits per Year

Providers/Clinics #3

Doctors, specialists, hospitals, or healthcare facilities you prefer to use.
Provider's Name
Clinic/Hospital Name
Location of Medical Facility
City
# of Visits per Year

Providers/Clinics #4

Doctors, specialists, hospitals, or healthcare facilities you prefer to use.
Provider's Name
Clinic/Hospital Name
Location of Medical Facility
City
# of Visits per Year

Providers/Clinics #5

Doctors, specialists, hospitals, or healthcare facilities you prefer to use.
Provider's Name
Clinic/Hospital Name
Location of Medical Facility
City
# of Visits per Year

Pharmacy & Prescriptions

Preferred pharmacies and medications currently being taken.
Preferred Pharmacy
Upload medication lists here or enter below

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Prescription Name
Dosage
(mg, mcg, mi, etc.)
Frequency
(1xday, 2xday, 1xmonth, 1xyear, etc.)
Form
(tablet, capsule, inhaler, nebulizer, injection, infusion, etc.)
Who takes this medication?

Additional Comments:
For additional attachments, upload here.

If you have a loss of coverage letter you can upload that here
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Disclaimer: As a broker, I am authorized to sell Blue Cross, HealthPartners, & Medica insurance products through MNsure. Breitenfeldt Group may receive compensation from a health carrier for enrolling an individual into a particular health plan. The information on all qualified health plans offered through MNsure can be found on the MNsure website. Breitenfeldt Group does not charge any fee for our service.
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Contact information