Full Name *

Date of birth

SSN:

Phone *

Address

City

Postal code *

State *

Do you currently have health insurance? *

Does your employer offer insurance coverage?

Yes

Marital Status

Single

Married

Divorced

Widowed

Are you claiming any dependents on your taxes for 2024? *

Is your approximate household income for the year, 2024 over or under $14,580? *

How much is your estimated income for the year 2024?

By signing, I hereby give my permission to Benavest NPN: 17635734 (“Agent”) and all affiliated agents and agencies to serve as the health insurance agent or broker for myself and my entire household, if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following: 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 premium’s Providing ongoing account maintenance and enrollment assistance, as necessary) Responding to inquiries from the Marketplace regarding my application. I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I confirm that I have reviewed my completed application and that all information is accurate. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. 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.

Signature *

Clear

*By clicking "Submit," I provide my signature expressly authorizing Benavest and any of its partner companies to contact me at the telephone/email address provided via live, pre-recorded-. Or auto-dialed calls, emails, or text messages to confirm my interest in receiving quotes. I consent to receiving SMS messages, and data rates may apply. Message frequency may vary. Reply help for more assistance or STOP to OPT-out from messaging. I understand my signature is not a condition for purchasing any property, goods, or services, and I may revoke my consent at any time.