Enroll Below In $0 - Low-Cost Health Insurance Plans

Low-Income
Self-Employed
You must have a qualifying event to be approved (you get to choose one later)

Are you on Medicaid or Medicare? *

Yes

First Name *

Last Name *

Email *

Phone *

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: *

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

Please wait we are validating SSN...

Please Provide Valid Social Security Number *

Gender *

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: *

ONLY SELECT YES IF DEPENDENTS ARE CLAIMED BY YOU ON TAX RETURN.

Do you have tax dependents (typically children)? *

Dependents social security is only required if you want them to be covered. You can type: I can provide it later to my agent if you do not have it present

Dependent 1 Full Legal Name *

Dependent 1 Gender *

Dependent 1 Date of Birth MM-DD-YYYY *

Do you want to enroll dependent 1? *

Dependent 1 Social Security Number *

Do you have 2nd Dependent? *

Dependent 2 Full Legal Name *

Dependent 2 Gender *

Dependent 2 Date of Birth MM-DD-YYYY *

Do you want to enroll dependent 2? *

Dependent 2 Social Security Number *

Do you have 3rd Dependent? *

Dependent 3 Full Legal Name *

Dependent 3 Gender *

Dependent 3 Date of Birth MM-DD-YYYY *

Do you want to enroll dependent 3? *

Dependent 3 Social Security Number

Do you have 4th Dependent? *

Dependent 4 Full Legal Name *

Dependent 4 Gender *

Dependent 4 Date of Birth MM-DD-YYYY *

Do you want to enroll dependent 4? *

Dependent 4 Social Security Number

Do you have 5th Dependent? *

Dependent 5 Full Legal Name *

Dependent 5 Gender *

Dependent 5 Date of Birth MM-DD-YYYY *

Do you want to enroll dependent 5? *

Dependent 5 Social Security Number

Do you have more than 5 dependents? *

List the rest of your dependent information here

Projected income for this year

Most Recent Employer Name or Company Name if Self Employed *

Projected annual income for this year based on household size:

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

Employment status *

Signature *

Clear

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

Disqualify Lead

Disqualify

By clicking "Submit" or providing your information, you agree to the following terms, authorizations, and disclosures. This form is designed to comply with all applicable CMS, ACA, TCPA, FCC, HIPAA, and carrier regulations, and may serve as your official acknowledgment and signature for enrollment in a qualified health plan.

🔐 LEGAL ACKNOWLEDGMENTS & CONSENTS

1. Accuracy of Information

I confirm that all information I provided, including personal, household, and income data, is accurate and truthful to the best of my knowledge. I understand this information is required to determine eligibility for coverage and applicable subsidies.

2. Appointment of Agent (Back-End Assignment)

I understand that a licensed agent, certified for Marketplace enrollments, may be assigned to my case based on availability, state licensing, and plan suitability. This agent may assist with:

Enrollment

Policy changes

Claims and servicing

Plan upgrades or renewals

This appointment remains valid for 12 months and renews annually unless revoked in writing.

3. Health Sherpa / Enrollment Platform Use

I acknowledge that the enrollment may be processed using a CMS-approved Enhanced Direct Enrollment (EDE) platform such as HealthSherpa, and may use a licensed NPN on record to finalize my application.

4. HIPAA & PHI Authorization

I authorize the agent or platform to access, transmit, and store my protected health information (PHI) as needed to:

Determine plan eligibility

Process applications

Service my policy

I understand this is compliant with HIPAA and may be revoked at any time by written request.

5. Communication Consent (TCPA Compliance)

I provide express written consent to be contacted by phone, text (SMS), email, or prerecorded/AI-assisted calls by:

Licensed agents

Their partners and affiliates

Enrollment platforms acting on their behalf

I understand message/data rates may apply, and I may revoke consent at any time by replying “STOP” to texts or requesting removal by email/phone.

6. AI & Automated Communication Consent

I agree to receive communications via AI-based systems or virtual assistants to provide updates, reminders, and enrollment assistance. I may opt out anytime.

7. Purpose of Contact

Contact may relate to:

Health plan eligibility and enrollment

Policy changes, reminders, and renewals

Special Enrollment Period (SEP) notices

CMS compliance notifications

Related insurance products (e.g., dental, vision, life, or supplemental)

8. No Purchase Required

My consent is not a condition of purchase. I may explore health plan options without any obligation.

9. Agent Visibility & Privacy

While I may not see agent names or credentials on the survey or website front-end, all assigned agents are licensed and compliant with CMS, ACA, and state insurance regulations. Their contact info may be disclosed upon request.

10. CMS Marketplace Requirements

I understand CMS requires that agents obtain consent before submitting an application. I confirm I have reviewed or will review my application prior to submission and agree to retain records for at least 10 years per CMS guidance.

11. Plan Renewal & Upgrade Consent

I authorize automatic re-enrollment in my current plan and give permission to upgrade to a more suitable plan if available—based on my updated eligibility and benefits, as determined by the assigned agent.

12. Data Privacy & Record Retention

All information submitted will be securely stored and retained for at least 10 years in accordance with CMS, TCPA, and HIPAA guidelines. Information is not sold or shared beyond the purpose of providing insurance services.

13. Transparency & No Misleading Claims

I acknowledge that I have not been misled by any deceptive marketing, and that the terms, benefits, and process were explained truthfully. Any incentive or reward card offered was presented clearly and separately from plan benefits.

📣 Final Disclosure

This is a privately-owned website and is not affiliated with or endorsed by any government agency, including Healthcare.gov or CMS. Submitting this form does not enroll you in a health plan but allows a licensed agent to contact you and assist with your enrollment based on state and federal guidelines

I agree to be enrolled in the ACA plan I have chosen and authorize the licensed agent to process my enrollment request. *

Enroll Me

Application signature *

Clear

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

“I understand that plan options may not be shown at this time due to system limitations or availability in my area. I authorize the licensed Agent of Record to contact me with the best available $0 premium plan(s) for my review and approval prior to enrollment. I understand that the agent will explain the plan details and I must approve the plan before any enrollment is submitted

I agree

Plan Name

Selected Plan Image

Plan Carrier Name

Plan Premiums

Plan ID

Gross Premiums

Plan Deductible

Plan type

Max OOP

Brochure Url

Benefits Url

Plan 2 Benefits Url

Plan 2 Brochure Url

Plan 2 Carrier Name

Plan 2 Name

Plan 2 Id

Plan 2 Premiums

Plan 3 Carrier Name

Plan 3 Name

Plan 2 Type

Plan 3 Id

Plan 3 Premiums

Plan 3 Brochure Url

Plan 3 Benefits Url

Plan 3 Type