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First Name *

Last Name *

Phone *

Date of birth *

Social Security Number (SSN) *

Gender *

Male

Female

Do you currently have Medicare or Medicaid? *

Yes

Monthly Income *

Have you used tobacco 4 or more times a week for the past 6 months? *

Yes

Your Employment Information *

Employed

Unemployed

Receiving Social Security

Current Employer *

SSI Monthly Income *

Marital Status *

Single

Married

Divorced

Widowed

Spouse's Name *

Spouse's Date of Birth *

Has your spouse used tobacco 4 or more times per week for the past 6 months? *

Yes

Spouse's Employment *

Employed

Self Employed

Receiving Social Security

Unemployed

Spouse's Monthly Income (even if not included on your health insurance policy *

Do you want your spouse covered on this policy? *

Yes

Spouse's Social Security Number *

Will you be claiming dependents on your taxes? *

Yes

Child 1 Full Name

Child 1 DOB

Are there more children to add?

Yes

Child 2 Full Name

Child 2 DOB

Additional Dependents?

Yes

Child 3 Full Name

Child 3 DOB

Additional Dependents: Include all information below, including Full Name, DOB, and SSN.

By initialing below, you affirm that you have read, understand, and acknowledge the information included in your application and this acknowledgement.

Acknowledgement:
I give you, the agent, the agency, and any associated affiliates, permission to work on my behalf in the marketplace. This permission includes, but is not limited to, the following:

1) Search the marketplace for any existing plans or applications associated with my account.

2) Complete any existing or new application for eligibility for or enrollment into a Qualified Marketplace Health Plan or other government health plan applications and available tax credits.

3) Provide ongoing account maintenance or assistance as needed and respond to any inquiries from the Marketplace regarding my application.

I have reviewed my application. I confirm that all of the information I have provided is accurate and complete.

I agree to the above statement. Please get to work finding the best health care plan for me. I acknowledge that I have read and accept the information provided.

[Initial in the Box Below to Agree and Confirm]

Acknowledgement Initials *

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