Is HealthConnect currently paying your health insurance premium?* Yes No Step 1. Information about you First Name* Middle Initial Last Name* Suffix Date of birth* Month Day Year Home address* City*Town of AlbionVillage of BellevilleTown of BerryTown of Black EarthVillage of Black EarthTown of Blooming GroveTown of Blue MoundsVillage of Blue MoundsTown of BristolVillage of BrooklynTown of BurkeVillage of CambridgeTown of ChristianaTown of Cottage GroveVillage of Cottage GroveTown of Cross PlainsVillage of Cross PlainsTown of DaneVillage of DaneTown of DeerfieldVillage of DeerfieldVillage of DeForestTown of DunkirkTown of DunnCity of EdgertonCity of FitchburgCity of MadisonTown of MadisonVillage of Maple BluffVillage of MarshallTown of MazomanieVillage of MazomanieVillage of McFarlandTown of MedinaCity of MiddletonTown of MiddletonCity of MononaTown of MontroseVillage of Mt HorebTown of OregonVillage of OregonTown of PerryTown of Pleasant SpringsTown of PrimroseVillage of RockdaleTown of RoxburyTown of RutlandVillage of Shorewood HillsTown of SpringdaleTown of SpringfieldCity of StoughtonCity of Sun PrairieTown of Sun PrairieTown of VermontCity of VeronaTown of VeronaTown of ViennaVillage of WaunakeeTown of WestportTown of WindsorTown of YorkStateWisconsinZip Code* CountyDaneIs your mailing address different with your home address? Yes No If different, write your mailing address. Mailing address* City*Town of AlbionVillage of BellevilleTown of BerryTown of Black EarthVillage of Black EarthTown of Blooming GroveTown of Blue MoundsVillage of Blue MoundsTown of BristolVillage of BrooklynTown of BurkeVillage of CambridgeTown of ChristianaTown of Cottage GroveVillage of Cottage GroveTown of Cross PlainsVillage of Cross PlainsTown of DaneVillage of DaneTown of DeerfieldVillage of DeerfieldVillage of DeForestTown of DunkirkTown of DunnCity of EdgertonCity of FitchburgCity of MadisonTown of MadisonVillage of Maple BluffVillage of MarshallTown of MazomanieVillage of MazomanieVillage of McFarlandTown of MedinaCity of MiddletonTown of MiddletonCity of MononaTown of MontroseVillage of Mt HorebTown of OregonVillage of OregonTown of PerryTown of Pleasant SpringsTown of PrimroseVillage of RockdaleTown of RoxburyTown of RutlandVillage of Shorewood HillsTown of SpringdaleTown of SpringfieldCity of StoughtonCity of Sun PrairieTown of Sun PrairieTown of VermontCity of VeronaTown of VeronaTown of ViennaVillage of WaunakeeTown of WestportTown of WindsorTown of YorkStateWisconsinZip Code* CountyDaneContact Information Phone*Email What is the best way that we can contact you if we have questions about your application? Preferred contact method Phone Email Text Phone - main number*Email* Phone number*How much money do you make a year (your annual household income)? You must write the same amount as you wrote on your Health Insurance Marketplace application.*How many people are in your household? You must write the same number as you wrote on your Health Insurance Marketplace application.* Do any of the person being covered under this policy use tobacco? If you or a family member in your house use tobacco (smoke) you will pay a separate charge (more money) for health insurance. HealthConnect will not pay the tobacco surcharge (separate charge). You must pay the extra charge every month.* Yes No Race / Ethnicity* White / Caucasian - for example, German, Irish, Lebanese, and so on. Black / African American - for example, African American, Haitian, Nigerian, and so on. Latino / Hispanic - for example, Mexican, Mexican American, Puerto Rican, Cuban, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on. Native American / American Indian - for example, Navajo, Mayan, Tlingit, and so on. Asian / SE Asian - for example, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistan, Cambodian, and so on. Native Hawaiian / Other Pacific Islander - for example, Native Hawaiian, Guamanian, Chamorro, Samoan, Fijan, Tongan, and so on. Multi Racial Other Other race (please specify)* Preferred language* English Spanish Other Specify your preferred language* Step 2. Information about your health insurance Look at your Health Insurance Marketplace application. Which insurance plan did you choose?* Dean GHC Quartz Dean Health Plan Name (Plan ID)* Dean Silver Copay Plus 4800X (38345WI0010095) Dean Silver Classic 5000X (38345WI0010098) Dean Silver Value Copay 5000X (38345WI0010099) Dean Silver HSA-E 4500X (38345WI0010122) Dean Focus Network Silver Value Copay 5000X (38345WI0080046) Dean Focus Network Silver HSA-E 4500X (38345WI0080048) GHC - SCW Plan Name (Plan ID)* Silver Simple Choice 4550X Ded/7900 MOOP 94% (94529WI024005006) Silver 4900 Ded/7900 MOOP 94% (94529WI024005706) Silver 8000X Ded/8550 MOOP 94% (94529WI024006206) Select Silver Simple Choice 4550X Ded/7900 MOOP 94% (94529WI024001806) Select Silver 4900 Ded/7900 MOOP 94% (94529WI024005806) Select Silver 8000X Ded/8550 MOOP 94% (94529WI024006406) Quartz Health Insurance Plan Name (Plan ID)* Quartz ONE Silver I301-06 37833WI051010106 Quartz ONE Silver I301-06 With Dental 37833WI038010106 Quartz ONE Silver I302-06 37833WI051001806 Quartz ONE Silver I302-06 With Dental 37833WI038002806 Quartz ONE Silver I303-06 37833WI051001906 Quartz ONE Silver I303-06 With Dental 37833WI038002906 Quartz ONE Silver I304-06 Deductible 37833WI054003606 What is your member number for your health plan? If you don’t have a member number yet, what is your Health Insurance Marketplace (HealthCare.gov) application number?* Health plan member number HealthCare.gov Application /ID # Health plan member number* HealthCare.gov Application /ID #* How many people will be covered under this plan?* Before you bought insurance on the Health Insurance Marketplace this year, what insurance did you have? (check appropriate box)* None - I was uninsured BadgerCare Health Insurance Marketplace Plan Other (employer/ parent’s insurance policy/ other private insurance, COBRA, etc.) If Other, please explain type or name of insurer.* If you had BadgerCare, what was your HMO? (select one) Dean Group Health Cooperative-GHC Quartz Step 3. Information about your health insurance premium subsidyHas HealthConnect helped you pay for health insurance at any time since 2014?* Yes No If yes, what was the first year you received Health Connect assistance?* Look at your Health Insurance Marketplace application. Find the Premium Tax Credit section. How much of the health insurance tax credit are you eligible for?*Did you select the “Advance Payment” option for your Advance Premium Tax Credit? You must select the “Advance Payment” option in the Health Insurance Marketplace to be eligible for financial help from HealthConnect.* Yes No Look at your Health Insurance Marketplace application. How much is your monthly insurance premium?*What month will your insurance coverage begin?* January February March April May June July August September October November December How did you first hear about HealthConnect?* Insurer/ Broker Enrollment Assistor/Navigator 2-1-1 Service Provider Word of Mouth Flyer/print material Social Media (Facebook, Instagram, etc) Other Do you want to write any comments about your application? Step 5. Read & sign this applicationYou must check ALL of the boxes to submit your application.* a. All of the information I wrote on this application is true. I give permission to United Way and my insurance company to talk about the information on my application to decide if I am eligible for the HealthConnect. b. I understand that I have to pay the monthly tobacco surcharge if I or a family member in my house smoke or use tobacco. c. I understand that if I am approved for financial help from HealthConnect, United Way will pay my health insurance premium (monthly payment) directly to my insurer starting the month I am approved and ending in December 2021, as long as I remain eligible. If I have already paid the premium for the month I am approved, HealthConnect assistance will begin the following month. d. I understand that the HealthConnect program will not pay or reimburse me for any health insurance premium payments I made before my application was approved. e. I understand that HealthConnect will not pay any tax penalties that result from having 2 different insurance plans at the same time. f. I understand that HealthConnect pays for my 2021 health insurance premium only. g. I understand that HealthConnect assistance may not be used to cover outstanding debts from prior coverage. h. I give permission and consent to be contacted in the future by United Way of Dane County as it relates to my experience with the HealthConnect program. If you want an electronic copy of your application, enter your email address. You should print and keep a copy of this application. Email By placing your initials in the box below you are consenting to release your information listed above to the HealthConnect Program and to receive communication regarding your application status. Enter First and Last Name initials into the box below.* CommentsThis field is for validation purposes and should be left unchanged.
