Name *
Business Name
Email *
Phone
Type of Business (Industry)
# of Employees * 1 2 3 4 If 5+, request census form
Business Org * Sole Proprietor LLC S Corp C Corp Partnership Other
Business Zip *
County Business is in? King Snohomish
#1 Employee Name
Owner Yes No
Income Type Profits (Distributions) W-2 1099 W-2 & Profits Other
Did you receive a W-2 for Prior Year Income? Yes No Not Sure Not from this company Not last calendar year, but I will this calendar year
Age or DOB *
Coverage Type * Employee Only Employee & Spouse Employee & Children Emp, Spouse & Children Waiving
Waiver Reason On Spouse Group On Parent Group (age <26) On Medicare TriCare (VA) Individual or Exchange Plan None
Who is current coverage with? Group or Individual?
Spouse Age or DOB
Child 1 Age or DOB
Child 2 Age or DOB
Child 3 Age or DOB
Child 4 Age or DOB
Please elaborate on when your W-2 income started (important qualifier)
#2 Employee Name
Owner Yes No
Income Type Profits (Distributions) W-2 1099 W-2 & Profits Other
Received W-2 for Last Calendar Year? Yes No Not Sure Not from this company Not last calendar year, but yes for this calendar year
Age or DOB *
Coverage Type * Employee Only Employee & Spouse Employee & Children Emp, Spouse & Children Waiving
Waiver Reason On Spouse Group On Parent Group (age <26) On Medicare TriCare (VA) Individual or Exchange Plan None
Who is current coverage with? Group or Individual?
Spouse Age or DOB
Child 1 Age or DOB
Child 2 Age or DOB
Child 3 Age or DOB
Child 4 Age or DOB
#3 Employee Name
Owner Yes No
Income Type Profits (Distributions) W-2 1099 W-2 & Profits Other
Received W-2 for Last Calendar Year? Yes No Not Sure Not from this company Not last calendar year, but yes for this calendar year
Age or DOB *
Coverage Type * Employee Only Employee & Spouse Employee & Children Emp, Spouse & Children Waiving
Waiver Reason On Spouse Group On Parent Group (age <26) On Medicare TriCare (VA) Individual or Exchange Plan None
Who is current coverage with? Group or Individual?
Spouse Age or DOB *
Child 1 Age or DOB *
Child 2 Age or DOB
Child 3 Age or DOB
Child 4 Age or DOB
#4 Employee Name
Owner Yes No
Income Type Profits (Distributions) W-2 1099 W-2 & Profits Other
Received W-2 for Last Calendar Year? Yes No Not Sure Not from this company Not last calendar year, but yes for this calendar year
Age or DOB *
Coverage Type * Employee Only Employee & Spouse Employee & Children Emp, Spouse & Children Waiving
Waiver Reason On Spouse Group On Parent Group (age <26) On Medicare TriCare (VA) Individual or Exchange Plan None
Who is current coverage with? Group or Individual?
Spouse Age or DOB *
Child 1 Age or DOB *
Child 2 Age or DOB
Child 3 Age or DOB
Child 4 Age or DOB
How did you hear about us?
Green Financial Client? Yes No In Past
Are there significant health or prescription issues? (this simply helps in our recommendation)
Besides those listed above, have you paid anyone else on a 1099 or W-2 basis, even if only a few hours per week? Yes No Unsure
If yes, please explain. This information may help you qualify for a group plan even if this person is not eligible for coverage.
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