Affordable Health Choices

2026 Open Enrollment Form

It's that time of year again! To help me prepare for 2026 Open Enrollment, please take a few minutes to fill out this form.

Your updated information - including your estimated income, doctors, and medications - is crucial. It helps me find the right plan to fit your needs.

Name * Required

Phone * Required

Email * Required

Address * Required

Your Household Information * Required

EXISTING Clients: Please list any changes to your household since your last enrollment. This includes new members (e.g., a new baby or spouse) or members to be removed (e.g., a child who is no longer a dependent).

* Required

NEW clients: Please list everyone in your household who needs coverage. Please include their full name and date of birth.

What do you estimate your household's total income will be for 2026? * Required

To help me check if your current doctors and medications are covered by a plan, please list them below. * Required

Current Doctors & Specialists:

Current Medications:

Is there anything else you'd like me to know?

Helpful Hint: Please use this space to share any other information that you feel is important for me to know, such as: upcoming surgeries, specific health concerns, or any questions you have about your coverage.

As a service, I can also provide quotes for other types of coverage. Please check the box next to any you would like me to explore.

Dental Insurance

Vision Insurance

Life Insurance

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