Answer the Following Questions Accurately to Authorize Your Application!

Number of dependents in household

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

Primary First Name *

Primary Last Name *

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 *

City *

State *

Postal code *

Estimated household income

I give my permission to the agent 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 to use the information provided by me in writing, electronically, or by telephone for the following purposes:

Searching 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; or Responding to inquiries from the Marketplace regarding my Marketplace application for the next 60 months.

Your Agent: ((agent name))

Phone Number: ((agent phone))

Email Address: ((agent email))

Agent NPN: ((agent npn))

SMS (Text Message) Consent:

By providing your mobile number, you consent to receive

SMS (text message) communications from ((agent name)).

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. Also that your income falls in the following chart, qualifying you for the Zero Premium Health Coverage.

*not all applicants qualify for the subsidies and/or $500 Rewards.

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