Logout | View Home Page

Pre-Enrollment Questionnaire

Harris Agency ~ Traverse City ~ Pre-Enrollment Questionnaire

Use the secure online form below to submit your Pre-Enrollment Questionnaire. 

You can call us at 231.944.1400 with your personal questions.

* required

E-Mail Address *

Primary Contact (First and Last Name) *

Phone No. *

Date of Birth *

Address *

City *

State *

Zip Code *

County *

Spouse Name

Date of Birth



Date of Birth



Date of Birth

Are you or your spouse eligible for employer-sponsored group health insurance? *

Is anyone in your household receiving social security retirement income? *

Please tell us the number of people in your household:*

Please tell us how many total exemptions are on your Federal 1040 tax return: *

Please tell us who needs insurance: *

What is your estimated future 2021 Adjusted Gross Income (AGI)? Note:(AGI can be found on the bottom of the first page (Line 8b) of your Federal 1040 tax return):

Please provide us with a brief overview of the health & wellness of yourself/family (i.e., pre-existing conditions, prescription drug coverage, exposure to claims, etc.): *

Do you currently have a Marketplace application? *

If so, please tell us if you have recently made any changes to your application (ie., income change, address change, username or password change):

Tobacco Use *

Do you currently have insurance? If so, what is the name of the plan(s)? *

Please type the word from the image in this field.