Census Form | Benefit Innovations

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10517 24th Ave Eau Claire, WI 54703

(715) 456-5012

info@mysite.com

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Your Information is needed and is protected with us. Fill out the FORM below so that we can customize a Healthcare Plan for You

First name*

Last name*

Birthday*

Month

Day

Year

Email*

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

County of Residence*

When do You need Your Healthcare Coverage to start?

Effective Coverage Start Date

Type of Health Coverage Needed*

Individual

Individual & Spouse

Individual and Dependents

Spouse & Dependents

Whole Family

Other

Name and Birthdate of all those needing Healthcare Coverage

Spouse's Name

Birthdate MM/DD/YYYY

Dependent 1 - Name

Birthdate MM/DD/YYYY

Dependent 2 - Name

Birthdate MM/DD/YYYY

Dependent 3 - Name

Birthdate MM/DD/YYYY

Dependent 4 - Name

Birthdate MM/DD/YYYY

What Healthcare Network is being used or which would You prefer to use?

Preferred Healthcare Provider

MAYO

MARSHFIELD Clinics

OAKLEAF HEALTH System

ESSENTIA HEALTH

ASPIRUS HEALTH

Other

Other than for Injury, is anyone involved in ongoing Medical Treatment?

Yes or No

If YES, give a brief description of the condition:

Ongoing MEDICAL Treatment for:

Are there any Prescription Drugs being taken other than GENERIC?

BRAND or SPECIALTY Drug 1 (Name, Dosage, Frequency)

BRAND or SPECIALTY Drug 2 (Name, Dosage, Frequency)

BRAND or SPECIALTY Drug 3 (Name, Dosage, Frequency)

or UPLOAD your Electronic Prescription List (a picture of your list will work if clear enough to read)

SECURE File upload

Is Pregnancy Coverage needed?

Yes or No

Are You interested in applying for an income based ACA Health Plan from the FFM (federally facilited marketplace) Exchange?

Yes or No

Are You interested in comparing the options of a Tax Favored High Deductible HSA Plan (Health Savings Account)?

Yes or No

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