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By answering a few questions, we can find an insurance policy with coverage best suited for you.

Eligibility Check

APPLY FOR $0 OR LOW HEALTH COVERAGE SUBSIDY USING TAX CREDITS

Are you on Medicare or Medicaid? *

Yes

First Name *

Last Name *

Phone *

Email *

Mailing Address - No P.O Box

Address *

City *

State *

Postal code *

Trusted Form Ping Url

IP Address

Trusted Form Cert Url

Disqualify Lead

Disqualify

Gender *

Date of birth *

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

Please select your Marital Status *

Signature *

Clear

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)? *

Number of Tax Dependents (Typically children) *

Do you wish to enroll your dependents as well? *

Please list all your tax dependents Full Names and Date of Births - make sure the information provided is accurate *

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

Most Recent Employer Name or Company Name if Self Employed *

Application Enrollment And Agent Of Record Signature: *

Clear

Terms of Service:

By using our services, you agree to the following terms:

Representation:
You grant the authorized agent, as mentioned in the attestation
disclaimer, the authority to act on your behalf concerning health
insurance matters, including enrollment, renewals, and related
decisions.

Accuracy: You confirm that all information provided is
true and accurate. False or misleading information can lead to the
termination of services.

Revocation: Your consent remains in effect until you revoke it. You may revoke or modify your consent at any time.

Limitation
of Liability: The authorized agent and associated entities are not
liable for any errors or omissions in the services provided or for any
damages, including indirect or consequential damages.

Data
Collection: Our Agents collect Personally Identifiable Information
(PII) solely for the purposes mentioned in our Comprehensive Attestation
Agreement.

Data Protection: We are committed to ensuring the
privacy and safety of your PII. Your data will not be shared for any
purposes other than those explicitly stated in our agreement.

Income
Attestation: We use your income information solely to determine
eligibility for health insurance programs and potential subsidies.

TCPA Disclaimer:

By
providing your phone number, you expressly consent to receive
auto-dialed and/or pre-recorded telemarketing calls, text messages,
and/or emails from the authorized agent mentioned in the attestation
disclaimer at the phone number and email address you provided, including
for marketing purposes. You understand that consent is not a condition
of purchase. Message and data rates may apply.