$0 Health Insurance Plan + Premium Tax Credit

*If you qualify

Answer the Following Questions Accurately to Authorize Your Application!

Primary First Name *

Primary Last Name *

Primary Email (Can never have been used for this survey before). *

Primary Cell Phone (Can never have been used for this survey before). *

Primary Date of Birth MM-DD-YYYY *

Primary Gender *

Primary Applicant's Social Security Number *

Do You Have A Spouse To Enroll? *

Spouse Legal First Name *

Spouse Legal Last Name *

Date of Birth MM-DD-YYYY *

Spouse Gender *

Spouse's Social Security Number *

Do You Have A Dependent To Enroll? *

Dependent 1 Full Legal Name *

Dependent 1 Gender *

Date of Birth MM-DD-YYYY *

Dependent 1 Social Security Number *

Do You Have A Second Dependent To Enroll? *

Dependent 2 Full Legal Name *

Dependent 2 Gender *

Date of Birth MM-DD-YYYY *

Dependent 2 Social Security Number *

Do You Have A Third Dependent To Enroll? *

Dependent 3 Full Legal Name *

Dependent 3 Gender *

Date of Birth MM-DD-YYYY *

Dependent 3 Social Security Number *

Do You Have A Fourth Dependent To Enroll? *

Dependent 4 Full Legal Name *

Dependent 4 Gender *

Date of Birth MM-DD-YYYY *

Dependent 4 Social Security Number *

Do You Have A Fifth Dependent To Enroll? *

Dependent 5 Full Legal Name *

Dependent 5 Gender *

Date of Birth MM-DD-YYYY *

Dependent 5 Social Security Number *

Do You Have A Sixth Dependent To Enroll? *

Dependent 6 Full Legal Name *

Dependent 6 Gender *

Dependent 6 Date of Birth MM-DD-YYYY *

Dependent 6 Social Security Number *

Address

Street Address

City *

State *

Country

Postal Code *

Estimated household income

Number of dependents in household

I give my permission to the agent/agency listed below, or one of the designated agents listed below**, to serve as the health insurance agent or broker for myself and my entire household for purposes of enrollment in a Qualified Marketplace Health Plan. By consenting to this agreement, I also authorize said Agent, or his licensed designee to use the information provided by me in writing, electronically, or by telephone for the following purposes:

Your Agent/Agency:

Phone Number: (516) 828-8031

Email Address: [email protected]

Agent NPN:

SMS (Text Message) Consent:

By providing your mobile number, you consent to receive

SMS (text message) communications from .

**Designated Agents:

Upon signing & submitting this document I am confirming I DO NOT currently have Medicare, Medicaid, Group, federally recognized Tribes, or ANCSA shareholder Insurance Coverage.

By consenting to this agreement, I also authorize said Agent to use the information provided by me in writing, electronically, or by telephone for the following purposes:

I authorize the agent listed to search for an existing Marketplace application: Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP, or advance tax credits to help pay for Marketplace premiums. Providing ongoing account maintenance and enrollment assistance, as necessary. Responding to inquiries from the Marketplace regarding my Marketplace application for the next 60 months.

I understand said agent may receive a commission on a policy sold to me up to $30 per member per month depending on the carrier I select and the state where I reside

I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my agent at the email address or phone number provided below.

Msg & data rates may apply. You can opt out at any time by replying 'STOP'. By submitting this document, you agree the above information is true and accurate. Please note, not all applicants qualify for the subsidies and/or $500 Rewards. However, our insurance plans offer a range of benefits that could be advantageous for you. Upon signing & submitting this document, I am confirming I DO NOT currently have Medicare, Medicaid, Group, federally recognized Tribes, or ANCSA shareholder Insurance Coverage. We cannot take any actions that jeopardize these types of coverage.

Income

Authorization Date *

Authorization Signature *

Clear