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Answer the Following Questions Accurately to Authorize Your Application!

First Name *

Last Name *

Email *

Cell Phone *

What is your address where we can mail the cards?

Street Address *

City *

State *

Postal code *

Primary Date of Birth MM-DD-YYYY *

Primary Applicant's Social Security Number *

Do You Have A Spouse? *

Yes

Spouse Legal First Name *

Spouse Legal Last Name *

Spouse's Gender *

Spouse's Date of Birth MM-DD-YYYY *

Do You Have Any Dependents? *

Yes

Dependent 1 Full Legal Name *

Dependent 1 Gender *

Dependent 1 Date of Birth MM-DD-YYYY *

Do You Have A 2nd Dependent? *

Yes

Dependent 2 Full Legal Name *

Dependent 2 Gender *

Dependent 2 Date of Birth MM-DD-YYYY *

Do You Have A 3rd Dependent? *

Yes

Dependent 3 Full Legal Name *

Dependent 3 Gender *

Dependent 3 Date of Birth MM-DD-YYYY *

Do You Have A 4th Dependent? *

Yes

Dependent 4 Full Legal Name *

Dependent 4 Gender *

Dependent 4 Date of Birth MM-DD-YYYY *

Do You Have a 5th Dependent?

Yes

Dependent 5 Full Legal Name *

Dependent 5 Gender *

Dependent 5 Date of Birth MM-DD-YYYY *

1. Search for an existing Marketplace Plan; 2. Complete an application for eligibility and enrollment in a Marketplace Plan; 3. Provide ongoing maintenance and enrollment assistance; or 4. Respond to inquiries from the Marketplace regarding my application.

I confirm what I have shared is accurate and true for entry on my Marketplace Health Insurance Application, that I have read and consent with the terms and understand the above mentioned agent will safely store and use my personal identifiable information for the above stated purposes and by submitting this document you agree that your income falls within the chart below, that you do not have Medicare/Medicaid/Employer Coverage, and you do not use tobacco products, qualifying you for Zero Premium Health Coverage.

I understand my consent remains until I revoke it by emailing us at {{user.email}} {{location.email}}.

By providing your mobile number, you consent to receive SMS communications from {{user.name}} {{location.name}}. You can opt out any time by replying "STOP"

Authorization Date *

Authorization Signature - I authorize you to be my Agent of Record each month until I revoke consent and re-enroll me in the best plan during Open Enrollment if my current plan is discontinued. *

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