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ABOUT US
CONTACT US
PRIVACY POLICY
David
Lowe
Brenda
Lowe
Derek
Lowe
Bobby
Crawford
Erick
Torres
David Lowe Insurance Agency
Question? Call 843-667-1315
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Telephone
Street Address
City
Zip
County
Please list all family members even if no coverage is requested for them.
Adult 1
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Cover This Person
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
Any Other Income
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Employer offers Insurance?
Yes
No
Cost/month for employee only
Adult 2
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Cover This Person
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
Any Other Income
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Employer offers Insurance?
Yes
No
Adult 3
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Cover This Person
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
Any Other Income
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Employer offers Insurance?
Yes
No
Adult 4
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Cover This Person
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
Any Other Income
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Employer offers Insurance?
Yes
No
Adult 5
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Cover This Person
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
Any Other Income
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Employer offers Insurance?
Yes
No
Adult 6
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Cover This Person
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
Any Other Income
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Employer offers Insurance?
Yes
No
Adult 7
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Cover This Person
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
Any Other Income
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Employer offers Insurance?
Yes
No
Adult 8
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Cover This Person
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
Any Other Income
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Employer offers Insurance?
Yes
No
Adult 9
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Cover This Person
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
Any Other Income
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Employer offers Insurance?
Yes
No
Adult 10
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Cover This Person
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
Any Other Income
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Employer offers Insurance?
Yes
No
Child 1
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Child 2
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Child 3
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Child 4
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Child 5
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Child 6
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Child 7
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Child 8
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Child 9
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
Child 10
First name
Last name
Date of Birth
Social Security
US Citizen
Yes
No
Married
Yes
No
Use Tobacco Products?
Yes
No
Employer
Employer's Phone Number
Gross Income for 2022
I'll claim this person on my 2022 tax return?
Yes
No
Has Health Insurance now?
Yes
No
I authorize David lowe Insurance Agency LLC to be my agent of record and to discuss any matters regarding my application for health insurance including claims. The above information is true and I alone am responsible for its accuracy. I direct its use for: establishing an account on my behalf with Healthcare.gov, to qualify for a health insurance tax credit, and to enroll in my chosen insurance plan. I plan to report this same information on my income tax return.I understand that if I am married I will have to file a joint tax return. Everything contained on this form is strictly confidential protected health information. Unautorized use is a violation of federal law.
For office use only.
Signature
Date
