Do you have any dependants that need coverage?

Do you have tax dependents (typically children)?

Household Size #

We want to make sure we can get you a $0 Premium plan

Employment

Income Range

Primary Applicant

How do we get ahold of you?

Full Name *

Email *

Phone *

Whats your address so we can get the best plan in your area

Address

City

State

Postal code

We need to check your eligibility

Your Gender?

Date of birth

Marital Status

Social Security #

Primary Applicant Signature & date

Signature *

Clear

Signature Date *

I, give my permission to the agents of HealthPlan Advocates 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 Providing ongoing account maintenance and enrollment assistance, as necessary. Responding to inquiries from the Marketplace regarding my application. This authorization will remain in effect for 10 years or until revoked. 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. Accuracy of Information: I confirm all personal and income information provided is accurate, to determine eligibility for health insurance and subsidies. SEP Acknowledgment: I understand certain life events qualify me for a Special Enrollment Period. Communication Consent: I consent to HealthPlan Advocates contacting me about health insurance options via phone, email, or other methods. No Guarantees: There are no guarantees on specific outcomes, despite HealthPlan Advocates efforts to secure optimal benefits. Data Protection: My data will be kept private and used in compliance with data protection laws. Avoidance of Misleading Information: I have not been influenced by misleading advertisements, trusting in HealthPlan Advocates transparency. CMS Requirements: I am aware of and consent to CMS's documentation requirements for enrollment assistance. Right to Modify/Revoke Consent: I reserve the right to modify or revoke consent at any time.