Individual Fact Finder | Arch Brokerage

Complete the Individual Fact Finder form below to start the process.

Your answers are secure and confidential.

Name

First Middle Last

Phone

Are you an existing Arch Brokerage client?

Yes

Address*

Gender

Male

Female

Date of Birth

County*

Tobacco User?

Yes

Marital Status

Single

Married

Divorced

Household Size (# of individuals on tax return)

Annual Household Income (MAGI)

Required to determine if eligible for a subsidy.

📄 Download Income Worksheet

Current Insurance Carrier

Current Monthly Premium

End Date of Current Coverage*

Cost of Prescription Drugs

Coinsurance

Deductible

How did you hear about us?

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Address Line 1

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Address Line 2

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Zip Code

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City

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States

If Spouse/Dependents are currently covered and/or you would like coverage for them, please complete the following:

Spouse Name

Gender

Male

Female

D.O.B.

Dependent 1

Gender

Male

Female

D.O.B.

Dependent 2

Gender

Male

Female

D.O.B.

Dependent 3

Gender

Male

Female

D.O.B.

Dependent 4

Gender

Male

Female

D.O.B.

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Dependent 4

*What's a modified adjusted gross income (MAGI)?

The figure used to determine eligibility for premium tax credits and other savings for Marketplace health insurance plans and for Medicaid and the Children's Health Insurance Program (CHIP). MAGI is adjusted gross income (AGI) plus these, if any: untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest.
MAGI doesn't appear as a line on your tax return. To figure out your MAGI:
- Start with your adjusted gross income (AGI). This is the figure on IRS Form 1040, line 11 of your federal income tax return.
- Take your adjusted gross income amount and add any untaxed foreign income, non-taxable Social Security benefits, and tax-exempt interest. Don’t add any Supplemental Security Income (SSI) you got.
- For many people, their MAGI is the same as or very close to their adjusted gross income.

Individual Fact Finder 2025

Complete the Individual Fact Finder form below to start the process.

Your answers are secure and confidential.

If Spouse/Dependents are currently covered and/or you would like coverage for them, please complete the following:

Dependent 1

Dependent 2

Dependent 3

Dependent 4