2027 Open Enrollment Information

Please take 10-15 minutes to fill out this form completly, for the most accurate and up-to-date quotes.

Full name of individual completing this form, must be a member of the tax household.

ex. John Doe

Signature

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Email

Phone

Address

ex. 111 Health St Lincoln IL 62656, Logan County

Who will be included in your 2027 tax househould?

Tax household members will include spouse (must file jointly) and any dependents you will claim for the 2027 tax year.

List all tax household members with full names as they appear on your social security card, even if they are not applying for health coverage.

ex. John Adam Doe

Jane E Doe

List who needs health coverage.

ex. Jane Doe only

List tax household dates of birth

ex. 11/01/1978

01/26/1980

Marital Status

ex. Single or married for the 2027 plan year.

What is your 2027 estimated household income?

Modified Adjusted Gross Income (pre-tax). Please check out FAQs tab for questions on how to figure your estimate for the 2027 plan year.

Name of employer(s) and location

ex. Quest Coffee Shop, Lincoln IL

Are you offered employer coverage? If YES, please provide the monthly cost for the least expensive plan for employee-only and cost for employee + family coverage.

ex. NO. or YES, $360/month employee only $1,200/month employee + family

What is most important to you when choosing a health plan?

Are you interested in dental and vision coverage?

I am already enrolled in one or both options.

I am not interested in dental or vision coverage.

I would like dental and/or vision quotes along with my health insurance quotes.

Names of your doctors, along with any medical facilities or hospitals you would like to make sure are in-network with your health insurance. (Optional)

ex. Dr John Wahab, Memorial Hospital in Lincoln IL

List of any medications you would like covered under your health plan for 2027. (Optional)

ex. Atorvastatin 50mg tablet, Humalog KwikPen 200units injection

Do you anticipate any major medical procedures in 2027, such as surgery, pregnancy, physical therapy etc? (Optional)