First Name
*
Last Name
*
Phone
*
Email
*
What product(s) are you interested in?
ACA Marketplace
Private Health (Off-Exchange)
Dental & Vision
Life Insurance
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
No
If you are eligible for a $0 monthly plan because of your income level, do you want us to process your enrollment into the best available plan immediately or to text you to before enrollment?
You have my consent to enroll me in the best plan available to me. I acknowledge I can always make adjustments later on.
Text me before you enroll me in a ACA plan to confirm.
Click here
to learn more about Dental & Vision benefits only.
Date of birth
Male or Female
M
F
Have you used tobacco 4 or more times a week for the past 6 months?
YES
NO
Address
*
Address
*
Country
Country
State
*
City
*
Postal code
*
Employer Name
Estimated Monthly Income
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
No
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
No
Spouse's Social Security #?
Are you claiming any dependents on your taxes?
Yes
No
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
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. This permission should include but not be limited to the following: 1) Search the Marketplace for any existing plans or applications associated with your account. 2) Complete any existing application for eligibility or enrollment for a Qualified Marketplace Health Plan or other government health plan applications and available tax credits. 3) Provide ongoing account maintenance or assistance as needed and respond to any inquiries from the Marketplace regarding your application. 4) You authorize me to renew your plan annually. I will attempt to keep you with the same company, but if premiums increase significantly or renewal with the same company is not possible, you give me full authority to switch you to the best available plan at that time. 5) You waive and release any and all rights to file grievances or complaints against me with the Federally Facilitated Marketplace (healthcare.gov), any state’s Department of Insurance, HealthSherpa, or the Centers for Medicare & Medicaid Services (CMS) I understand that this permission will remain in effect until I revoke it and I may do so at any time via text to (813) 686-7438 or
[email protected]
Signature
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Clear