Name *
Business Name
Email *
Phone
Type of Business (Industry)
# of Employees * Choice 1 1 2 3 4 If 5+, request census form
Business Org * Choice 1 Sole Proprietor LLC S Corp C Corp Partnership Other
Business Zip *
County Business is in? King Snohomish
#1 Employee Name
Owner Choice 1 Yes No
Income Type Choice 1 Profits (Distributions) W-2 1099 W-2 & Profits Other
Did you receive a W-2 for Prior Year Income? Choice 1 Yes No Not Sure Not from this company Not last calendar year, but I will this calendar year
Age or DOB *
Coverage Type * Choice 1 Employee Only Employee & Spouse Employee & Children Emp, Spouse & Children Waiving
Waiver Reason Choice 1 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 Choice 1 Yes No
Income Type Choice 1 Profits (Distributions) W-2 1099 W-2 & Profits Other
Received W-2 for Last Calendar Year? Choice 1 Yes No Not Sure Not from this company Not last calendar year, but yes for this calendar year
Age or DOB *
Coverage Type * Choice 1 Employee Only Employee & Spouse Employee & Children Emp, Spouse & Children Waiving
Waiver Reason Choice 1 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 Choice 1 Yes No
Income Type Choice 1 Profits (Distributions) W-2 1099 W-2 & Profits Other
Received W-2 for Last Calendar Year? Choice 1 Yes No Not Sure Not from this company Not last calendar year, but yes for this calendar year
Age or DOB *
Coverage Type * Choice 1 Employee Only Employee & Spouse Employee & Children Emp, Spouse & Children Waiving
Waiver Reason Choice 1 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 Choice 1 Yes No
Income Type Choice 1 Profits (Distributions) W-2 1099 W-2 & Profits Other
Received W-2 for Last Calendar Year? Choice 1 Yes No Not Sure Not from this company Not last calendar year, but yes for this calendar year
Age or DOB *
Coverage Type * Choice 1 Employee Only Employee & Spouse Employee & Children Emp, Spouse & Children Waiving
Waiver Reason Choice 1 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? Choice 1 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? Choice 1 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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