Medicaid/Medicare Coverage

Are you currently on Medicaid or medicare? *

Yes

No

Medicaid/Medicare Confirmation

You said you have Medicaid or Medicare coverage, is that correct? *

Yes, I have Medicaid or Medicare

No, that's not correct OR I will be losing Medicaid coverage shortly and need ACA coverage

Employment Info

What is your current employment status? *

Employed

Unemployed

Receiving Social Security

Your Employer Information

Employer :

Monthly Income : *

Marital Status

What is your marital status?

Single

Married

Divorced

Widowed

Spouse's Informatiom

Spouse's Name *

Souse's Date of Birth : *

Spouse's Employment

Employed

Unemployed

Social Security Benefits

Spouse's Monthly Income *

Souses's Social Security #

Monthly Social Security Income

What is your monthly social security income? *

Your Dependents

Do you want children covered on the policy? (must be claimed as a dependent on your taxes)

Yes

No

Dependant Information

Child's Full Name *

Child's Date of Birth *

Child's Social Security #

If there are multiple dependents, please list their full name, date of birth, and social security # below.

Doctor Information

Do you have a primary doctor you see regularly?

Yes

No

Primary Doctor Information

Primary Care Doctor's Full Name

Primary Care Doctor's City

Primary Care Doctor's address

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First Name *

Last Name *

Date of birth *

Phone *

Email *

Address *

State *

Postal code *

Social Security Number *

Agree to attestation *

I Agree

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