ACA Policy Help Obamacare Plan

MARKET PLACE INSURANCE APPLICATION

Lets start with some basic information

First Name *

Last Name *

Birthday *

Phone *

Email *

Address *

City *

State *

Postal code *

Do you Smoke? *

Yes

Male or Female? *

Male

Female

Do you currently have any health insurance through any of the following? *

Whats your Medicare #?

Medicare #

Part A Effective Date

Part B Effective Date

I DON'T have my Medicare card with me!

What Is Your Marital Status

Marital Status *

Single

Married

Divorced

Widowed

Spouse's Information

Spouse's Name *

Spouse's DOB *

Spouse's Employment *

Employed

Unemployed

Social Security Benefits

Spouse's 2024 Estimated Annual Income *If Any

Do You Want Your Spouse Covered On This Policy? *

Yes

Spouse's Social Security #?

Personal Employment Info

Employment Information *

Employed

Unemployed

Receiving Social Security

Monthly Social Security Income

Monthly Social Security Income *

Employer Information

Employer Name *

2024 Annual Income *

Dependents

Do you want Children Covered On The Policy? *

Yes

Child's Information

Child's Full Name *

Child's DOB *

Child's SSN *

If there are multiple dependents, please list additional information here

Doctor Information

Do You Have A Primary Care Doctor You See Regularly? *

Yes

Doctor Information

Doctors Full Name *

Doctors City *

Currently taking any Prescribed Medications?

YES

Please list Prescribed Medications only.

Final Step... Almost Done!

What is your Social Security #? *

Authorization

By clicking this box you agree that all of the information provided is correct. You also agree to allow Avid Health to process your health insurance application with the information given, and you are not covered by medicaid.

I, give Gerrick Diaz NPN 18447456 and/or his agency affiliates 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 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:

1. Searching for an existing Marketplace application;

2. 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;

3. Providing ongoing account maintenance and enrollment assistance, as necessary; or

4. Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that the Agent 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 emailing in to [email protected].

Signature *

Clear

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