AFFORDABLE AMERICAN HEALTH CARE

AFFORDABLE AMERICAN

HEALTH CARE

Get NEW Subsidized MarketPlace

Affordable Care Now!

We are here to help!

One of our Marketplace Specialists will process your application to get you the best coverage possible

First Name

Last Name

Date of birth

Male or Female

Have you used tobacco 4 or more times a week for the past 6 months?

YES

Phone *

Email *

Address *

City *

State *

Postal code *

Marital Status *

Single

Married

Divorced

Widowed

Spouse's Name

Spouse's DOB

Has your spouse used tobacco 4 or more times a week for the past 6 months?

Yes

Spouse's Employment

Employed

Self-Employed

Social Security Benefits

Unemployed

Spouse's 2022 Estimated Monthly Income* PLEASE INCLUDE EVEN IF YOU DO NOT WANT THEM ON YOUR HEALTH INSURANCE POLICY

Do you want your spouse covered on this policy?

Yes

Spouse's Social Security #?

Your Employment Information *

Employed

Unemployed

Receiving Social Security

Employer Name

2022 Estimated Monthly Income

SSI Monthly Income *

Are you claiming any dependents on your taxes for 2022?

Yes

Child's Full Name *

Child's DOB *

Child's SSN *

if there are multiple dependents, please list additional information here

Doctor's Full Name

Doctor's City

In Order to get a Cost Sharing Reduction and an Advanced Premium Tax Credit you will need to file a tax return for the upcoming year. Will you file a tax return for the coming year?

Yes

What is your social security #? *

Broker/Agent Consent

By Clicking this box,I give my permission to Bryce Casson NPN 20706820 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 the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: 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, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums; Providing ongoing account maintenance and enrollment assistance, as necessary; or Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the Bryce Casson NPN 20706820 will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting Bryce Casson NPN 20706820 at anytime. You also attest that all of the information is true and correct to the best of your knowledge. You are also giving Bryce Casson NPN 20706820 the permission to process your application with the information given to us.

Signature *

Clear

Get NEW Subsidized MarketPlace

ObamaCare Now!

We are here to help!

One of our Marketplace Specialists will Process your application to get you the best coverage possible

First Name

Last Name

Date of birth

Male or Female

Have you used tobacco 4 or more times a week for the past 6 months?

YES

Phone *

Email *

Address *

City *

State *

Postal code *

Marital Status *

Single

Married

Divorced

Widowed

Spouse's Name

Spouse's DOB

Has your spouse used tobacco 4 or more times a week for the past 6 months?

Yes

Spouse's Employment

Employed

Self-Employed

Social Security Benefits

Unemployed

Spouse's 2022 Estimated Monthly Income* PLEASE INCLUDE EVEN IF YOU DO NOT WANT THEM ON YOUR HEALTH INSURANCE POLICY

Do you want your spouse covered on this policy?

Yes

Spouse's Social Security #?

Your Employment Information *

Employed

Unemployed

Receiving Social Security

Employer Name

2022 Estimated Monthly Income

SSI Monthly Income *

Are you claiming any dependents on your taxes for 2022?

Yes

Child's Full Name *

Child's DOB *

Child's SSN *

if there are multiple dependents, please list additional information here

Doctor's Full Name

Doctor's City

In Order to get a Cost Sharing Reduction and an Advanced Premium Tax Credit you will need to file a tax return for the upcoming year. Will you file a tax return for the coming year?

Yes

What is your social security #? *

Broker/Agent Consent

Signature *

Clear

Affordable American Healthcare™

AFFORDABLE AMERICAN HEALTH CARE

AFFORDABLE AMERICAN

HEALTH CARE

Get NEW Subsidized MarketPlace

Affordable Care Now!

Get NEW Subsidized MarketPlace

ObamaCare Now!

One of our Marketplace Specialists will Process your application to get you the best coverage possible

All Rights Reserved - 2023

All Rights Reserved - 2023