Answer the Following Questions Accurately to Authorize Your Application!

I give my permission to the agent listed below to serve as the health insurance agent or broker for myself and my entire household for purposes of enrollment in a Qualified Marketplace Health Plan. By consenting to this agreement, I also authorize said Agent to use the information provided by me in writing, electronically, or by telephone for the following purposes:

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 for the next 60 months. 

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 at the following email address below or phone number below; 

Name of Primary Writing Agent:

Phone Number: (866) 889-1312

Email Address:

SMS (Text Message) Consent:

By providing your mobile number, you consent to receive

SMS (text message) communications from Byron Johnson and

Msg & data rates may apply. You can opt out at any time by replying "STOP".

By submitting this document, you agree the above information is true and accurate. Also that your income falls in the following chart, qualifying you for the Zero Premium Health Coverage.  

*not all applicants qualify for the subsidies and/or $500 Rewards.

Upon signing & submitting this document I am confirming I DO NOT currently have Medicare, Medicaid, Group, federally recognized Tribes, or ANCSA shareholder Insurance Coverage. We cannot take any actions that jeopardize these types of coverage.


Verify Your Marketplace Application Information

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.