Apply For Subsidized Healthcare and Benefits

Do you or anyone in your household applying for coverage have Medicare, Medicaid or VA coverage? * *

Yes

First Name *

Last Name *

Phone *

Email *

ADDRESS - NO P.O BOX

Address *

City *

State *

Postal code *

Trusted Form Cert Url

Trusted Form Ping Url

IP Address

Gender *

Citizenship: Require to validate your eligibility: *

Date of birth *

Main applicant's Social Security (needed to authenticate your application) *

Please select your Marital Status *

Please enter your Spouse's First Name *

Please enter your Spouse's Last Name *

Spouse Date Of Birth *

Do you wish to enroll your Spouse as well? *

Spouse SSN: *

Spouse Gender *

Do you have tax dependents (typically children)? *

Number of Tax Dependents (Typically children) *

Please list all your tax dependents Full Names and their Date of Births *

Do you wish to enroll your dependents as well? *

Please Be Accurate - Income Will Be Verified By Healthcare.gov

What is your projected annual household income for this year? *

Are you currently Employed: *

Current/Past Occupation/Job Title *

Comprehensive Attestation Agreement

I give my permission to Bryan Lantry 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 Bryan Lantry to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of: 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 Bryan Lantry will not use or share my personally identifiable information (PII) for any purposes other than those listed above. Bryan Lantry will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. Income Attestation: I confirm that the information I've provided regarding my income is true and accurate. I further attest that I will be making the minimum required income to qualify for subsidized healthcare under the Federally Facilitated Marketplace. I understand that this information will be used to determine my eligibility for health insurance programs and potential subsidies. Scope of Appointment: I appoint Bryan Lantry as my authorized representative and Agent of Record for the purposes of: Searching for and completing applications on the Marketplace. Handling renewals and making necessary changes to my health insurance plan. Providing ongoing account maintenance and enrollment assistance. Responding to inquiries from the Marketplace regarding my application. By this agreement, I designate Bryan Lantry to represent and assist me in all interactions with the health insurance provider for a duration of up to 3 years. By signing below, you acknowledge the following: You agree to the terms and conditions outlined in this attestation. You respectfully request Bryan Lantry's expertise to enroll you and/or your family in the most suitable zero premium ACA plan available. In the event that no zero premium health plan is available in your area, you understand that we will disclose the available plans and seek your consent before proceeding with enrollment. You authorize Bryan Lantry to access your healthcare.gov account and submit the necessary information as required. Bryan Lantry, NPN: 18971049 [email protected] *

I agree

Signature *

Clear

By signing below, you attest that the previously provided information constitutes the information used to create your Marketplace application and that you have reviewed this information and it is accurate. *I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information. *

Application Signature *

Clear