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

Low-Income
Self-Employed

Are you on Medicaid or Medicare? *

Yes

Legal First Name (As it appears on your driver’s license) *

Legal Last Name (As it appears on your driver’s license) *

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 Provide Valid Social Security Number *

Please wait we are validating SSN...

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: *

Do you have tax dependents (typically children)? *

IMPORTANT:

We will need to know all dependent's information whether they will be enrolling in the health plan or not. Accurate dependent information will help us determine your subsidy amount (if any) you will receive.

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

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 *

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 *

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 *

Dependent 3 Social Security Number

Do you have 4th Dependent? *

Dependents social security is only required if you want them to be covered

Dependent 4 Full Legal Name *

Dependent 4 Gender *

Dependent 4 Date of Birth MM-DD-YYYY *

Dependent 4 Social Security Number

Do you have 5th Dependent? *

Dependents social security is only required if you want them to be covered

Dependent 5 Full Legal Name *

Dependent 5 Gender *

Dependent 5 Date of Birth MM-DD-YYYY *

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.

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.

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, and plan upgrades or renewals. This appointment remains valid for 12 months and renews annually unless revoked in writing.

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.

I authorize the agent or platform to access, transmit, and store my protected health information (PHI) as needed to determine plan eligibility, process applications, and service my policy. I understand this is compliant with HIPAA and may be revoked at any time by written request.

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, and 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 or phone.

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

Contact may relate to health plan eligibility and enrollment, policy changes, reminders, and renewals, Special Enrollment Period (SEP) notices, CMS compliance notifications, and related insurance products such as dental, vision, life, or supplemental plans.

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

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 information may be disclosed upon request.

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.

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.

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.

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.

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.

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 ID

Plan Premiums

Plan type

Benefits Url

Brochure Url

Plan 2 Id

Plan 2 Type

Plan 2 Name

Plan 2 Benefits Url

Plan 2 Brochure Url

Plan 2 Premiums

Plan 2 Carrier Name

Plan 3 Premiums

Plan 3 Name

Plan 3 Brochure Url

Plan 3 Id

Plan 3 Carrier Name

Plan 3 Type

Plan 3 Benefits Url