Individual & Family Plans Healthcare Questionaire

Individual & Family Plans Healthcare Questionaire
Contact information

Please provide all information below as this is the information used to prepare your 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 reside in?
Date of Birth

MonthDayYear
Date
Are you seeking coverage?
Gender
Tobacco User
Household Information

Household is based on your TAX household - anyone you file taxes with or claim as a dependent. (Spouse, Dependent Children, etc.)
If no one else is in your household, please continue onto the next section

Spouse or Dependent Information
Name

First NameLast Name
Spouse or Dependent
Date of Birth

MonthDayYear
Date
Are they seeking coverage?
Gender
Tobacco User

Spouse or Dependent # 2
Name

First NameLast Name
Spouse or Dependent
Date of Birth

MonthDayYear
Date
Are they seeking coverage?
Gender
Tobacco User

Spouse or Dependent # 3
Name

First NameLast Name
Spouse or Dependent
Date of Birth

MonthDayYear
Date
Are they seeking coverage?
Gender
Tobacco User

Spouse or Dependent # 4
Name

First NameLast Name
Spouse or Dependent
Date of Birth

MonthDayYear
Date
Are they seeking coverage?
Gender
Tobacco User

Spouse or Dependent # 5
Name

First NameLast Name
Spouse or Dependent
Date of Birth

MonthDayYear
Date
Are they seeking coverage?
Gender
Tobacco User

Spouse or Dependent # 6
Name

First NameLast Name
Spouse or Dependent
Date of Birth

MonthDayYear
Date
Are they seeking coverage?
Gender
Tobacco User

Income

If you choose NOT to provide income information, we will prepare full price quotes and we will not check for any premium reduction for your household.
Income we request is the ANNUAL income for the year you are seeking coverage. Premiums & coverage can change based on the projected household income.

Example: If you want coverage for July 2026; we need the projected income of January-December 2026 for the entire tax household.

For more infomration visit: Household Income / MNsure

Income Level Guidelines for Financial Help
Projected Modified Adjusted Gross Income

Other Considerations
Are you interested in a Dental Plan?
Please list provider name and clinic:
Are you interested in a Vision Plan?
Please list provider name and clinic:

Doctors/Clinics
Practitioner's Name
Clinic/Hospital Name
Location of Medical Facility
City
# of Visits per Year

Doctors/Clinics # 2
Practitioner's Name
Clinic/Hospital Name
Location of Medical Facility
City
# of Visits per Year

Doctors/Clinics # 3
Practitioner's Name
Clinic/Hospital Name
Location of Medical Facility
City
# of Visits per Year

Doctors/Clinics # 4
Practitioner's Name
Clinic/Hospital Name
Location of Medical Facility
City
# of Visits per Year

Doctors/Clinics # 5
Practitioner's Name
Clinic/Hospital Name
Location of Medical Facility
City
# of Visits per Year

Pharmacy & Prescriptions
Preferred Pharmacy
Attach Medications 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?

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?

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?

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

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 any additional attachments, please 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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