Secure Insurance - ACA Health Plan Request Form

You & how to reach you

Basic contact details, plus a quick profile of your own coverage needs.

Last name

First name

M.I. (optional)

Date of birth

Email

Phone

Home street address

City

State

ZIP code

County

Preferred way to be contacted (select all that apply)

Phone call Text Email No preference

Please select at least one contact method.

Will you (the person filling out this form) be covered on the plan we're researching?

Yes No – covered elsewhere Not sure

Please select one option.

Do you currently have health coverage?

Yes No N/A / Unknown

Please select one option.

Tobacco use (select N/A if under the legal age to purchase tobacco)

Yes No N/A – under legal age

Please select one option.

Special circumstances: are you a parent or legal guardian of a child under age 19?

Yes No

Please select one option.

Your doctors, medications & expected care

Type "N/A" in any box below that truly doesn't apply to you.

Doctors, specialists, or hospitals you want to keep

Regular prescription medications (name + dosage if known)

Anything expected in the next 12 months that affects your care needs?

Planned surgery/procedure Pregnancy / planning Ongoing specialist care New to the area N/A – none of the above

Please select at least one option (or N/A).

Anything else about your health care needs?

Household & tax filing

Marketplace subsidies (premium tax credits) are based on your household size and income as reported on your tax return.

Tax filing status

Total people on your tax return

Estimated total household income for the coverage year (gross, before taxes)

Any income that varies or is hard to estimate? (self-employment, tips, seasonal work, etc.)

Other household members

Add everyone else who lives in your household or will be considered for coverage. If it's just you, you can skip this and continue to the next section.

Reason for shopping

Helps me understand the timing and whether you qualify for a special enrollment period.

Why are you shopping for a new plan right now?

Month you need coverage to start

Year

Coverage starts on the 1st of the month you choose. If you're not certain, choose “Not sure yet” and we'll sort out timing together.

Budget & plan preferences

There's usually a trade-off between monthly premium and how much you'd pay when you actually use care. This tells me where you'd rather flex. If something doesn't apply, choose N/A.

Comfortable monthly premium

Comfortable with a higher deductible in exchange for a lower premium?

Rank what matters most (1 = most important, 4 = least)

Lowest possible monthly premium
Keeping my current doctors
Low out-of-pocket costs when I need care
Prescription drug coverage

Plan type preference

HMO PPO EPO No preference

Please select one option.

If unsure, I can advise.

Interested in an HSA-eligible plan? (lets you save pre-tax for medical costs)

Yes No Not sure, explain options N/A

Please select one option.

Any carriers you'd like me to prioritize? (select all that interest you)

Blue Cross Blue Shield of MI

Priority Health

Health Alliance Plan

Ambetter

UnitedHealthcare

—

No preference

Please select at least one option (or "No preference").

Anything else?

Use this space for anything not covered above. If nothing else applies, type "N/A."

Let's find the right plan for you

You & how to reach you

Your doctors, medications & expected care

Household & tax filing

Other household members

Reason for shopping

Budget & plan preferences

Anything else?

Your summary