Answer the Following Questions Accurately to Authorize Your Application!

First Name *

Last Name *

Email *

Phone *

What is your address where we can mail the cards?

Address

Street Address

City

State

Country

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 Gender *

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

Do You Have Any Dependents? *

Yes

Dependent 1 Full Legal Name *

Dependents 1 Date of Birth MM-DD-YYYY *

Dependent 1 Gender *

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 Date of Birth MM-DD-YYYY *

Dependent 4 Gender *

Do You Have a 5th Dependent?

Yes

Dependent 5 Full Legal Name *

Dependent 5 Date of Birth MM-DD-YYYY *

Dependent 5 Gender *

I agree that I have read this attestation and I give my permission to: [Agent/Broker Name], [ National Producer Number [ __________], [Phone], [Email], to serve as my broker for myself and my household, for the purpose of enrollment in a qualified Health Plan offered by the Federally Facilitated Marketplace. I consent to allow the above mentioned agent to view and use my confidential information for the following purposes:

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

I confirm that:

The information I provide is true and accurate.
I have reviewed the eligibility application, including all attestations at the end of the application, and confirm its accuracy before submission.
I understand and consent to the terms and authorize the above-named agent/broker/agency to securely use my personal identifiable information for the purposes above.
My information will be protected when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII, and it will not be used for any purposes other than those listed.
By submitting this form, I confirm that my household income falls within the chart below, that I do not have Medicare/Medicaid/Employer coverage, and that I do not use tobacco products, qualifying myself for Zero Premium Health Coverage.
This consent will remain in effect until 11/1/35 unless I revoke it earlier. I may revoke or modify this consent at any time by contacting my agent/broker/agency by email at [EMAIL], by phone at [PHONE], or by mailing a written notice.

I understand that this signed consent and application review confirmation will be kept by my agent/broker/agency for at least ten (10) years and may be provided to CMS upon request.

By providing my mobile number, I consent to receive SMS communications from [Agent Name]. I may opt out of texts at any time by replying “STOP.”

YES, let's find the best $0 health insurance plan I can qualify for.

Authorization Signature - Please Sign Below to grant consent to be enrolled in the best health plan you qualify for.

Signature *

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