Health Care is Changing

PDCM Insurance can help you determine if you are on the BEST health care plan available and if you are eligible to receive a subsidy. You have the right to know what options are available to you for health care. We will never charge you for professional agent guidance.

To better assist you with determining your health care options, we ask that you fill out the following form.
You may also print out this form, complete and bring to our office.

Personal Information

Full Name (First, Middle, Last)
Date of Birth (xx/xx/xxxx)
Tobacco UseYes

Address (PO Box, Suite, Apartment #)
Zip Code
Phone Number
Email Address
Preferred method to reach youPhone

Do you qualify for a subsidy? If you would like to find out, please include your Annual Household Income. This field is ONLY required to determine if you qualify for a subsidy.

Annual Household Income
Household Size (# of current residents in home)

Spouse Information

If you do NOT have a spouse, check here.
Spouse's Full Name
Spouse's Date of Birth
Does your spouse use tobacco?Yes

Dependent Information

If you do NOT have any dependents, check here.
Dependent's Full Name
Dependent's Date of Birth
Does your dependent use tobacco?Yes
More Dependents? Please supply their information here.

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ALL INFORMATION ENTERED IS CONFIDENTIAL. We take pride in considering all information as personal and confidential. You can feel safe with your information in our hands. We use a secure network, and treat all information as personal and confidential.

We appreciate you taking the time to complete the form. Our licensed staff will promptly enter your information. If you have any questions regarding this process, you are always welcome to call our office at (319) 234-8888.

I certify that all statements are true to the best of my knowledge and belief and I understand that a copy of this form will be made available to me at my request.

Re-Enter Full Name as Signature