First Name *

Last Name *

Phone *

Email *

Date of birth

Male or Female

Have you used tobacco 4 or more times a week for the past 6 months?

YES

Address *

City *

State *

Country

Postal code *

Marital Status *

Single

Married

Divorced

Widowed

Spouse's Name

Spouse's DOB

Has your spouse used tobacco 4 or more times a week for the past 6 months?

Yes

Spouse's Employment

Employed

Self-Employed

Social Security Benefits

Unemployed

Spouse's Estimated Monthly Income*

PLEASE INCLUDE EVEN IF YOU DO NOT WANT THEM ON YOUR HEALTH INSURANCE POLICY

Do you want your spouse covered on this policy?

Yes

Spouse's Social Security #?

Your Employment Information *

Employed

Unemployed

Receiving Social Security

Employer Name

Estimated Monthly Income

SSI Monthly Income *

Are you claiming any dependents on your taxes?

Yes

Child's Full Name *

Child's DOB *

Child's SSN *

if there are multiple dependents, please list additional information here

Doctor's Full Name

Doctor's City

In Order to get a Cost Sharing Reduction and an Advanced Premium Tax Credit you will need to file a tax return for the upcoming year. Will you file a tax return for the coming year?

Yes

What is your social security #? *

Agent/Broker Consent *

By Clicking this box,I give my permission to Johnny Woo NPN 18447961 and/or Zaneta Woo NPN 20545090 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 telephone only for the purposes of 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 premiums; Providing ongoing account maintenance and enrollment assistance, as necessary; or Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the Johnny Woo NPN 18447961 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 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 Johnny Woo NPN 18447961 at anytime. You also attest that all of the information is true and correct to the best of your knowledge. You are also giving Johnny Woo NPN 18447961 the permission to process your application with the information given to us.

As per CMS guidelines please acknowledge that you give me, JOHNNY WOO and/or ZANETA WOO and agency owner, “DANIEL VILLA” of “FIDES INS.” and the agents affiliated with our agency to work on your behalf in the Marketplace. Search and compare all Marketplace plans for you Review your current application and update income/household info if needed Enroll you in the plan that gives you the lowest monthly payment and best coverage For future years: Send you renewal options every Open Enrollment Automatically re-enroll you in the same or better plan if we don’t hear back from you within 14 days of our renewal notice Switch you to a more affordable plan if your current premium increases more than 10% (we will always notify you first) You are confirming that all information on your application is true and accurate to the best of your knowledge. You can cancel this authorization anytime by texting (813)-686-7438 STOP or emailing [email protected]

Signature *

Clear