Are you currently employed? *

Yes

Name of Your Employer *

Do you have insurance through your employer, Medicare or VA?* *

First Name *

Last Name *

Street Address (Physical) *

City (Physical) *

State (Physical) *

Postal Code (Physical) *

Gender *

Male

Female

Phone *

Social Security - Main ACA Applicant *

Email *

Main Applicant Birth Date (D.O.B.) *

Spouse Name

Spouse Date of Birth

Spouse Social Security Number

How many people need coverage? *

Dental Interest

I'd also like a quote on Dental Insurance

Expected Household Income Per Month *

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

You attest that your estimated income for 2023 will be at least the Federal Poverty Limit for your state and household requirements . You agree to notify us as soon as you become aware of any changes to expected income per month that you provided above. Failure to notify us of any changes may result in your eligibility being affected.

Income Verification Consent *

In some cases, it may be necessary to verify your income. If income verification is required in order to complete your enrollment, do you authorize Fides Insurance Agency to submit an income attestation letter on your behalf with the information that you have provided?

Verification of Information; Consent to Enrollment *

By Checking This Box I Hereby Provide Consent and authorization To Fides Insurance Agency, LLC. To Enroll Me And/Or My Family In A Health Insurance Plan Through The ACA Marketplace. If I Already Have A Plan, I Request That Fides Insurance Agency, LLC. And Its Agents Become My Agent Of Record And Switch Me To A Better Plan If One Is Available. This consent will remain in effect unless and until rescinded by you in writing by emailing [email protected].

REVISED APPOINTMENT OF FIDES INSURANCE LLC as Authorized Representative / Power of Attorney:

DISCLOSURES REGARDING LIMITED POWER OF ATTORNEY

The following limited power of attorney authorizes Fides Insurance LLC to make decisions regarding your insurance matters. This limited power of attorney does not grant Fides Insurance LLC or any other individual the authority to make decisions concerning your medical care. The following limited power of attorney becomes effective immediately upon execution. In the event that Fides Insurance LLC is unable or unwilling to act on your behalf after you execute this limited power of attorney, we will provide you with notice, and this power of attorney will be terminated.

Please carefully review the limited power of attorney. If you have any inquiries regarding this power of attorney or the authority you are conferring upon Fides Insurance LLC, it is advisable to seek legal counsel before signing this document.

FORM OF LIMITED POWER OF ATTORNEY

I hereby grant Fides Insurance LLC limited authority to undertake any and all actions required to select, obtain, and maintain insurance coverage for myself and any dependents through any applicable insurance marketplace or exchange, including, but not limited to, the following actions:

Select an insurance plan on my behalf.

Apply for and enroll me (as well as any dependents) in the chosen insurance plan.

Add or remove coverage.

Establish or modify beneficiary or dependent designations.

Update contact information for myself, dependents, or beneficiaries.

Update details relevant to eligibility for insurance subsidies.

Submit supplementary documents to an insurance marketplace or exchange, such as income verification and social security numbers.

Maintain my insurance coverage by renewing it periodically.

Adjust the insurance plan at renewal if a more suitable plan is available.

Take any other lawful actions pertaining to insurance coverage.

The authority granted to Fides Insurance LLC under this power of attorney shall cease upon my death, incapacity, or if I revoke the power of attorney in writing to Fides Insurance LLC.

Any individual, including but not limited to Fides Insurance LLC, any online broker acting on behalf of Fides Insurance LLC in submitting an insurance application, and the relevant insurance marketplace or exchange, may rely on the validity of this limited power of attorney or a copy thereof, unless they are aware that it has been terminated.

Acknowledgements

I hereby signify my agreement with the foregoing by signing below *

Clear