Client Intake Form

Used to gather client data for Healthcare.gov enrollments

Step 1 of 5

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Your Personal Information

Your Name(Required)

First MI Last

Date of Birth(Required)

MM slash DD slash YYYY

SS#(Required)

Gender(Required)

Male

Female

Tobacco User(Required)

Yes

Email Address(Required)

Enter Email Confirm Email

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Address County(Required)

Mailing Address (If Different)

Street Address Address Line 2 City State ZIP Code

Coverage & Income

Are you applying for coverage for yourself?(Required)

Yes

I want to see if I qualify for lower costs through the Federal Marketplace:(Required)

Yes

I am a US Citizen, Permanent Green Card Holder or have legal immigration status:(Required)

Yes

Are you federally recognized as an Alaskan Native or Native American?(Required)

Yes

Do you plan to file a federal tax return?(Required)

Yes

Tax Filing Status:(Required)

Single

Married Filing Jointly

Married Filing Separately

Head of Household

Your Income(Required)

Please tell us about your sources of income (W-2 employment, self employment or 1099, retirement, investment, pension, Social Security, ETC) Click the + symbol to add additional sources of income

Name of Source of Income

Project Annual Income for 2025

Employer Phone # (if applicable)

Dependent Information

Do you have a spouse?(Required)

Yes

Spouse Name(Required)

Please enter information even if your spouse does not need coverage

First MI Last

Date of Birth(Required)

MM slash DD slash YYYY

SSN(Required)

Gender(Required)

Male

Female

Tobacco User(Required)

Yes

Applying for coverage?(Required)

Yes

Spouse Income(Required)

Please tell us about your sources of income (W-2 employment, self employment or 1099, retirement, investment, pension, Social Security, ETC) Click the + symbol to add additional sources of income. If this person ahs no income please enter N/A in the "Type" box.

Name of Source of Income

Project Annual Income for 2025

Employer Phone # (if applicable)

How many dependents will you claim on your 2024 tax return?(Required)

Dependent Name(Required)

First MI Last

Date of Birth(Required)

MM slash DD slash YYYY

SSN(Required)

Gender(Required)

Male

Female

Tobacco User(Required)

Yes

Applying for coverage?(Required)

Yes

Dependent Income(Required)

Name of Source of Income

Project Annual Income for 2025

Employer Phone # (if applicable)

Dependent Name(Required)

First MI Last

Date of Birth(Required)

MM slash DD slash YYYY

SSN(Required)

Gender(Required)

Male

Female

Tobacco User(Required)

Yes

Applying for coverage?(Required)

Yes

Dependent Income(Required)

Name of Source of Income

Project Annual Income for 2025

Employer Phone # (if applicable)

Dependent Name(Required)

First MI Last

Date of Birth(Required)

MM slash DD slash YYYY

SSN(Required)

Gender(Required)

Male

Female

Tobacco User(Required)

Yes

Applying for coverage?(Required)

Yes

Dependent Income(Required)

Name of Source of Income

Project Annual Income for 2025

Employer Phone # (if applicable)

Dependent Name(Required)

First MI Last

Date of Birth(Required)

MM slash DD slash YYYY

SSN(Required)

Gender(Required)

Male

Female

Tobacco User(Required)

Yes

Applying for coverage?(Required)

Yes

Dependent Income(Required)

Name of Source of Income

Project Annual Income for 2025

Employer Phone # (if applicable)

Dependent Name(Required)

First MI Last

Date of Birth(Required)

MM slash DD slash YYYY

SSN(Required)

Gender(Required)

Male

Female

Tobacco User(Required)

Yes

Applying for coverage?(Required)

Yes

Dependent Income(Required)

Name of Source of Income

Project Annual Income for 2025

Employer Phone # (if applicable)

Dependent Name(Required)

First MI Last

Date of Birth(Required)

MM slash DD slash YYYY

SSN(Required)

Gender(Required)

Male

Female

Tobacco User(Required)

Yes

Applying for coverage?(Required)

Yes

Dependent Income(Required)

Name of Source of Income

Project Annual Income for 2025

Employer Phone # (if applicable)

Prescription and Provider Information

Medications (Rx)

Please list any current medications being taken. Click the + symbol to add additional medications.

Person Taking Rx

Rx Name

Dosage

Frequency

Providers

Please specify any specific physicians or clinics you currently utilize . Click the + symbol to add additional providers.

Physician First & Last Name

Facility/Hospital Name

City, State

Additional Questions

Are interested in dental coverage for yourself or your family?(Required)

Yes

Dentist Information

Click the + symbol to add additional Dentists

Dentist First & Last Name

Facility Name

City/State

Are interested in vision coverage for yourself or your family?(Required)

Yes

Optometrist Information

Click the + symbol to add additional Optometrists

Optometrist First & Last Name

Facility Name

City/State

Are you offered coverage from an employer of your own or spouses regardless of cost?(Required)

Yes

What is the Employer only cost for the lowest cost plan available?(Required)

What is the cost to add the spouse and/or family to the lowest cost plan?(Required)

Have you lost qualifying coverage in the last 60 days or expect to in the next 60 days?(Required)

Yes

What date is the loss of coverage?(Required)

MM slash DD slash YYYY

Please provide a copy of the loss of coverage letter:

Upload your resume in .pdf, .doc or .docx format

Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Does anyone listed above qualify for Medicaid?(Required)

Yes

Who qualifies for Medicaid?(Required)

Has anyone listed above recently been denied Medicaid Eligibility?(Required)

Yes

Who was denied?(Required)

When was the denial?(Required)

MM slash DD slash YYYY

Please provide a copy of the Medicaid denial letter:

Upload your resume in .pdf, .doc or .docx format

Accepted file types: pdf, doc, docx, Max. file size: 25 MB.

Your Agent Name(Required)

E-Signature Consent(Required)

Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures

Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.

You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below.

Scope of Consent
By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below.

Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies.

Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.

Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.

“Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.

“Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .

“Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.

The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.

I agree to the terms and conditions for e-signatures.

CMS Marketplace Consent(Required)

I give permission to OCI Insurance & Financial Services or its designated agent representatives, Charles Olson,
Christian Morton, Christopher Basile, Jessica Fletcher, George (Joe) Gordon, or Yvonne Warren (collectively, the “Agent”) to serve as the health insurance Agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on a Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned agent to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following:

• Searching for an existing marketplace application
• Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advanced tax credits to help pay for Marketplace premiums
• Providing ongoing account maintenance and enrollment assistance, as necessary
• Responding to inquiries from the Marketplace regarding my application

I understand that the Agent will not use or share my personal identifiable information (PII) for any purposes other than those listed above. The agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes.

I confirm that the information I provided for entry on my marketplace eligibility and enrollment application will be true to the best of my knowledge.

I understand that I do not have to share additional personal information about myself or my health with my agent beyond what is required on an application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by emailing individualadmin@ociservices.com.

Name of Agency: OCI Insurance & Financial Services
National Producer Number: 7438843
Owner of Agency: Charles Olson
Phone Number: 402-330-8700
Email Address: individualadmin@ociservices.com

I agree to the terms and conditions for the CMS marketplace consent.

Client Signature(Required)

Email
This field is for validation purposes and should be left unchanged.