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First Name *

Last Name *

Phone *

Address *

City *

State *

Postal code *

Do you currently have Medicare or Medicaid? *

Yes

Email *

Date of birth *

Gender *

Male

Female

Monthly Income *

Social Security Number (SSN) *

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 *

Spouse's Social Security Number *

Do you want your spouse covered on this policy? *

Yes

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 signing this form, you acknowledge and agree:

1. You confirm that the information you've provided on the application is accurate to the best of your knowledge.

2. You permit your agent, or an employee working under your agent, to access your healthcare.gov account. This access is to help renew your coverage, respond to requests for additional information, and update items as needed or requested.

3. You grant your agent the authority to act as the agent of record on your account, enabling them to complete the aforementioned tasks and inform you if your account requires more information. If your current plan best suits your needs, your agent will assume the role of the broker and maintain your plan.

4. You permit your agent to periodically review your account as necessary to provide you with updates on required documentation from Healthcare.gov, including but not limited to proof of income, incarceration, and citizenship requests.

5. You understand that if your plan is altered by another agent, you grant permission for your agent to assume control over the new plan and notify you of the change. This permission is valid for two years from the consent date and can be extended for another two years by responding to emails, text messages, or participating in a phone call with your agent.

6. You acknowledge that you can revoke these permissions at any time in writing via email or text message, or by giving verbal notice during a phone call with your current agent.

Signature

Clear

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