APPLY FOR $0 HEALTH COVERAGE SUBSIDY USING TAX CREDITS

Are you on Medicaid or Medicare? *

Yes

First Name *

Last Name *

Phone *

Email *

ADDRESS

Address *

City *

State *

Postal code *

Trusted Form Cert Url

Trusted Form Ping Url

IP Address

Gender *

Date of birth *

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 *

I wish to enroll my spouse as well *

Spouse SSN *

Do you have tax dependents (typically children)? *

Number of Tax Dependants (Typically children) *

Do you wish to enroll your dependents as well? *

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

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

Income source *

I certify that I will be making the minimum income required for a subsidized healthcare *

Consent and Attestation Agreement I hereby give my permission to Robert Lewis, NPN: 9755131, Chris Grzybowski, NPN : 17820955, Philip Stietzel, NPN : 8520913 Email : [email protected] as mentioned in this agreement, 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 Robert Lewis to: View and use the confidential information provided by me in writing, electronically, or by telephone 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. Providing ongoing account maintenance and enrollment assistance, as necessary. Responding to inquiries from the Marketplace regarding my application. Act as my Agent of Record concerning all matters related to my health insurance. This designation allows Robert Lewis to represent and assist me in all interactions with the health insurance provider. Ensure that my Personally Identifiable Information (PII) is kept private and safe when collecting, storing, and using it for the purposes stated above. Robert Lewis commits to not sharing my PII for any purposes other than those explicitly stated in this agreement. I further attest to one or more of the following conditions being true: My income meets the minimum required to qualify for subsidized healthcare under the Federally Facilitated Marketplace. I, or someone in my household, has experienced a qualifying life change in the past 60 days that qualifies for a Special Enrollment Period. I, or someone in my household, either lost qualifying health coverage in the past 60 days or expects to lose coverage in the next 60 days. Scope of Appointment: I appoint Robert Lewis, NPN: 9755131, as my representative for up to 10 years for the purposes mentioned above. Revocation: I understand that my consent remains in effect until I revoke it. I may revoke or modify my consent at any time by contacting Robert Lewis at [email protected]. Notice: I understand that I may be required to verify the information provided in this attestation. I must attest that the information I provide is true, including the facts that qualify me for enrollment. I may be required to submit documents that confirm my eligibility based on the conditions I've attested to. By signing below, I acknowledge the terms and conditions outlined in this attestation.

I agree

I have reviewed my application information above, and here is my signature *

Clear

I hereby confirm that I have reviewed and understand the details of the health plan I am enrolling in, including coverage, premiums, and deductibles. I acknowledge that I have been provided with all the necessary information to make an informed decision about my health insurance coverage. *

Clear