Do you currently have: Medicaid, Medicare?

Or did you enroll in any marketplace/aca plan (like Ambetter) currently?

Yes

First Name *

Last Name *

Phone *

Email *

Mailing Address - No P.O Box

Address *

City *

State *

Zip Code *

Trusted Form Ping Url

IP Address

Trusted Form Cert Url

Main Applicant Date of Birth: *

Gender *

Main applicant's Social Security (We need this to verify your marketplace application) *

Please select your Marital Status *

Please enter your Spouse's First Name *

Please enter your Spouse's Last Name *

Spouse Gender *

Spouse Date Of Birth *

Do you want to enroll spouse as well? *

Spouse SSN: *

Do you have tax dependents (typically children)? *

Number of Tax Dependents (Typically children) *

Do you wish to enroll your dependents as well? *

Please list your dependents names and date of births. If you chosen to enroll your dependents, please provide their social security numbers to be able to enroll in the health subsidy. *

Projected income for this year

Disqualify Lead

Disqualify

Most Recent Employer Name or Company Name if Self Employed *

Projected annual income for this year based on household size: *

Estimated 2025 Gross Income *

Employment status *

Signature *

Clear

Invalid signatures (dots, marks, etc.) may result in application denial. Please provide a clear, valid signature.

Consent and Acknowledgment: By completing this form, I consent to provide my personal and health-related information to determine my eligibility for health insurance subsidies and coverage. I understand this information may be used to match me with licensed insurance agents who can assist with my insurance needs. Agent Assignment and Information Disclosure: Generic Agent Assignment: My information will be distributed to various qualified agents without specific agent details (such as name and NPN) immediately available. This is to ensure that I am matched with an agent who best meets my specific requirements. Data Protection and Privacy: PII Handling: All personal and income-related information will be handled in compliance with relevant data protection regulations to ensure my privacy and security. CMS and Marketplace Compliance: This process adheres to the Centers for Medicare & Medicaid Services (CMS) guidelines, ensuring that all interactions and data handling meet federal and state requirements. Documentation of Consent and Compliance with CMS Regulations: Consent Documentation: This form serves as documentation of my permission to use and share my information as described. This consent is documented digitally with a timestamp and is maintained for a minimum of 10 years as required by CMS. Review and Confirmation of Application Information: Before any application is submitted on my behalf, I will review and confirm the accuracy of the information. Documentation of this review will also be maintained in accordance with CMS regulations. Right to Modify or Revoke Consent: I may modify or revoke this consent at any time by providing written notice to the managing agent or agency. Special Enrollment Periods (SEP) and Communication Consent: SEP Acknowledgment: I understand that certain life events may qualify me for a Special Enrollment Period, and I authorize my assigned agent to assist me in applying for coverage during such times. Communication Preferences: I consent to receive communications about health insurance options and benefits via phone, email, or other methods from assigned agents. I can opt out of these communications at any time. No Guarantees: While agents will strive to provide the best possible benefits based on my circumstances, there are no guarantees regarding specific outcomes. Acknowledgment of Advertisements and Information Accuracy: I have not been influenced by misleading advertisements. All information provided will be accurate and transparent, adhering to the highest standards of honesty and integrity in the enrollment process. Legal and Compliance Assurance: This form includes all necessary legal assurances to meet CMS requirements for online enrollments and auto-enrollment processes, safeguarding against any potential disputes or compliance issues. Signature and Confirmation: By signing below, I confirm that I have read, understood, and agreed to all terms outlined in this consent form. I acknowledge that this consent is voluntary and informed.

Application signature *

Clear

Invalid signatures (dots, marks, etc.) may result in application denial. Please provide a clear, valid signature.

I want The Agent of Record to choose the best available $0 plan in my area

I agree

Plan Name

Selected Plan Image

Plan Carrier Name

Plan ID

Plan type

Brochure Url

Benefits Url