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Health / Marketplace Preliminary Intake
Complete these preliminary questions if you selected Health Insurance / ACA Marketplace.
Household Size
Estimated Annual Household Income Range
Select Under $20,000 $20,000–$34,999 $35,000–$49,999 $50,000–$74,999 $75,000–$99,999 $100,000+
Current Health Coverage
Select Yes No Coverage ending soon
Possible Qualifying Event
Select Loss of health coverage Moved / changed residence Marriage Birth / adoption Household or income change Other / not sure None
Consumer Authorization & Consent — MIAG Insurance Group
I authorize MIAG Insurance Group to contact me regarding insurance and Health Insurance Marketplace® coverage options and, when requested by me, to assist me with reviewing eligibility, available plans, enrollment options, and permitted Marketplace updates.
I understand that submitting this form does not enroll me in any insurance plan, does not guarantee eligibility for coverage or financial assistance, and does not obligate me to purchase insurance.
I authorize MIAG Insurance Group to use the information I voluntarily provide for the purpose of assisting me with insurance and Marketplace-related services. I understand that additional information, identity confirmation, and additional consumer review or consent may be required before an application, enrollment, or change is submitted.
I understand that I may revoke this authorization by contacting MIAG Insurance Group, subject to any applicable record-retention requirements.
I have read the authorization above and authorize MIAG Insurance Group as stated.
For your protection, do not enter Social Security numbers, banking details, account passwords, or detailed medical information on this website form.
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