• Fort Dodge
    515-576-1800
  • Manson
    712-973-0379
  • Johnston
    515-505-3111
  • Arnolds Park
    712-332-8361
  • Rock Valley
    712-476-9655

Marketplace Annual Review Form

  • MM slash DD slash YYYY
  • Do you have any dependents that need removed from your plan January 1, 2023?

    If yes, please list the name(s) of dependents to be removed:
  • First NameLast NameDate of Birth 
    Use the + icon at the end of each row to add additional rows as needed
  • Do you have any dependents that need to be added to your plan January 1, 2023?

    If yes, please list the name(s) of dependents to be added:
  • First NameLast NameDate of BirthGenderTobacco Use 
    Use the + icon at the end of each row to add additional rows as needed
  • MM slash DD slash YYYY


  • By signing my name below I acknowledge and agree that:

    I have read the Privacy Notice Statement Pertaining to Personally Identifiable Information and I hereby authorize KHI Solutions to collect and use my PII to the extent reasonably necessary to assist in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHP's through the Marketplace, and/or applying for Federal subsidies, and any other health related plan.