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Pre-Application Worksheet

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Herr Insurance and Assistance Services
Healthcare Exchange Application Worksheet
* Bring this information to your appointment. This information will be used for the purposes of completing
your application and then will be returned to you. No record of your information beyond your name, address,
phone number, and plan selected will be maintained by Herr Insurance and Assistance Services*

Have you purchased Health Insurance through the healthcare exchange previously?
Yes

No

If yes, what is your healthcare.gov username: ___________________________ &
password: _________________________________
Your Name: ____________________________ Your Phone # ____________________
Your Address: _________________________________________________________
_____________________________________________________________________
Your D.O.B __________ Your SS# (if applying for coverage for yourself) _________________
Family Members Applying for Coverage:
Name:________________________ D.O.B._________ SS#______________________
Name:________________________ D.O.B._________ SS#______________________
Name:________________________ D.O.B._________ SS#______________________
Name:________________________ D.O.B._________ SS#______________________
Name:________________________ D.O.B._________ SS#______________________
Name:________________________ D.O.B._________ SS#______________________
Name:________________________ D.O.B._________ SS#______________________
How would you rank your health insurance understanding?:
• I am very knowledgeable I am only seeking help due to a special circumstance or problem.
• I am knowledgeable, but have had problems in the past, or feel there are some areas that I need
assistance or education.
• I do not understand this stuff. Please help me!

Pre-Application Worksheet
Your Households Income
Please list your household’s sources of income from an employer:
Employment 1: Person Employed __________________________________________
Place of Employment/ Employer’s Name _____________________________________
Employer’s address _____________________________________________________
City ____________________________ State______ Zip ________________________
Name of benefit contact person: (optional) ____________________________________
Salary: $________________ per:( hour/ week/ biweekly/ year) hours worked per week ____

Employment 2: Person Employed __________________________________________
Place of Employment/ Employer’s Name _____________________________________
Employer’s address _____________________________________________________
City ____________________________ State______ Zip ________________________
Name of benefit contact person: (optional) ____________________________________
Salary: $________________ per:( hour/ week/ biweekly/ year) hours worked per week ____

Employment 3: Person Employed __________________________________________
Place of Employment/ Employer’s Name _____________________________________
Employer’s address _____________________________________________________
City ____________________________ State______ Zip ________________________
Name of benefit contact person: (optional) ____________________________________
Salary: $________________ per:( hour/ week/ biweekly/ year) hours worked per week ____

Employment 4: Person Employed __________________________________________
Place of Employment/ Employer’s Name _____________________________________
Employer’s address _____________________________________________________
City ____________________________ State______ Zip ________________________
Name of benefit contact person: (optional) ____________________________________
Salary: $________________ per:( hour/ week/ biweekly/ year) hours worked per week ____

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Pre-Application Worksheet

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List any sources of income that are not from employment (e.g. Child Support/ Social
Security/ Workman's Compensation/ Retirement….)
$________________ per ____________________ from _______________________
$________________ per ____________________ from _______________________
$________________ per ____________________ from _______________________
$________________ per ____________________ from _______________________
Health Information:
How would you rate your health?
1.) I am very healthy and rarely visit the doctor or hospital. I do not take any
medications regularly.
2.) I am generally healthy, I see my physician a couple of times per year and take
some maintenance medications.
3.) I have chronic health conditions that require physician monitoring and I take
medications routinely to manage my medications.
4.) I have chronic and severe health conditions and/or I take multiple medications
or use medical devices to keep me healthy.
Do you take any medications or use any medical devices regularly? If So, Please List:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Pre-Application Worksheet
Do you have physicians or hospitals that you regularly see or prefer to use? If so,
please list:
Physician or Clinic: ____________________________________________________
Address: ____________________________________________________________
City:___________________________ State: ________ Phone: _________________
Physician or Clinic: ____________________________________________________
Address: ____________________________________________________________
City:___________________________ State: ________ Phone: _________________
Physician or Clinic: ____________________________________________________
Address: ____________________________________________________________
City:___________________________ State: ________ Phone: _________________
Physician or Clinic: ____________________________________________________
Address: ____________________________________________________________
City:___________________________ State: ________ Phone: _________________
Physician or Clinic: ____________________________________________________
Address: ____________________________________________________________
City:___________________________ State: ________ Phone: _________________
Physician or Clinic: ____________________________________________________
Address: ____________________________________________________________
City:___________________________ State: ________ Phone: _________________

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