Health Insurance Questionnaire
Your employer has partnered with Monarch Agency Solutions to help you access the most amount of benefits for the least cost possible. 

Please complete the following form to the best of your ability. 

We will use this form to determine your family's eligibility. 
There are programs to help cover part or even ALL of your monthly health insurance premiums.
This comes in the form of a tax subsidy in which 8 in 10 families are qualifying for at the moment. 

This means your health insurance premiums may be low cost or even no cost. 
This is based on household size, status of insurance and income. 

Once you complete the following information, an agent will input this into the system and will take a look to see which policies are best for you and your family based on your zip code, doctors and medications. You will then hear back with a couple of options to choose from.

If you have any questions, please contact Ho Tran at 425-505-5657
Sign in to Google to save your progress. Learn more
Email *
Your First Name, Last Name *
Street number, Street Name *
City *
State *
Zip Code *
County *
Your Date of Birth *
Gender at Birth *
How many people live in your home? 

(These would be people who also are on your taxes with you. No need to list roommates. Include yourself in this number)
How many of those people are applying for insurance?  *
What is your tax household income?

This is all income that is reported on taxes regardless of who is applying for coverage.

If you are married please include both incomes. If you are self employed this is the number after deductions.

In order to qualify for the subsidy you MUST file jointly if you are married. Include both incomes in this number.
Please check all that apply in the last 60 days: *
Email address

This is where your quote and documents will go.
Mobile Phone Number

We may text you when we are working on your file if we need more information.
Are you a citizen? *
What country were you born in? *
Social or TIN *
Employer Name
Your Title
Employer Address
Employer Phone
Your Annual Income from this employer only.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy