Form – Center of Affordable Health Insurance

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- Step 1 of 11

Insurance or this

WHAT’S YOUR LEGAL NAME?

As it appears on your driver’s license

First Name *

Last Name *

WHERE DO YOU WANT YOUR POLICY MAILED?

NO P.O. BOXES, PLEASE!

Street Address *

City *

State *

Zip Code *

Email *

Phone Number *

SSN *

Primary Date of Birth *

LET'S SEE IF YOU QUALIFY FOR $0 HEALTH INSURANCE

SELECT INDIVIDUALS QUALIFY FOR THE ACA PREMIUM TAX CREDITS, YOU MAY BE ONE OF THEM!

Gender *

Male
Female

Are you a U.S. citizen? *

Are you employed? *

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

Last Tobacco Used

Today
Yesterday
Last Week
Last Month

Name of employer *

Doctor's name

Doctor's city

ARE YOU SURE YOU ANSWERED THAT CORRECTLY?

Please confirm, are you a U.S. citizen? *

ARE YOU MARRIED?

YOU MAY BE ABLE TO QUALIFY YOUR SPOUSE, TOO!

Marital Status *

Single
Married

Spouse Info

Name *

First

Last

Spouse SSN *

Spouse Date of Birth *

Does this person need health insurance coverage? *

HOW ABOUT CHILDREN AND TAX DEPENDENTS?

YOU MAY BE ABLE TO QUALIFY THEM, TOO!

How many tax dependents do you have? *

None
1
2
3
4
5
More than 5

Dependent 1 Info

Dependent 1 Name *

First

Last

Dependent 1 Date of Birth *

Dependent 1 SSN *

Does this person need health insurance coverage?

Dependent 2 Info

Dependent 2 Name *

First

Last

Dependent 2 SSN *

Dependent 2 Date of Birth *

Does this person need health insurance coverage? *

Dependent 3 Info

Dependent 3 Name *

First

Last

Dependent 3 SSN *

Dependent 3 Date of Birth *

Does this person need health insurance coverage? *

Dependent 4 Info

Dependent 4 Name *

First

Last

Dependent 4 SSN *

Dependent 4 Date of Birth *

Does this person need health insurance coverage? *

Dependent 5 Info

Dependent 5 Name *

First

Last

Dependent 5 SSN *

Dependent 5 Date of Birth *

Does this person need health insurance coverage? *

More than Five Dependents

List the rest of your dependent information here

PREMIUM TAX CREDIT SUBSIDIES ARE BASED ON INCOME

BE ACCURATE TO ENSURE YOU RECEIVE THE RIGHT AMOUNT OF SUBSIDY AND NO REPAYMENT WILL BE REQUIRED AT TAX TIME

What is your projected annual household income (2025)? *

$21,597 - $21,972
$21,973 - $22,347
$22,348 - $22,723
$22,724 - $23,098
$23,099 - $23,474
$29,187 - $29,694
$29,695 - $30,201
$30,202 - $30,709
$30,710 - $31,216
$31,217 - $31,724
$36,777 - $37,416
$37,417 - $38,055
$38,056 - $38,695
$38,696 - $39,334
$39,335 - $39,974
$44,367 - $45,138
$45,139 - $45,909
$45,910 - $46,681
$46,682 - $47,452
$47,453 - $48,224
$51,957 - $52,860
$52,861 - $53,763
$53,764 - $54,667
$54,668 - $55,570
$55,571 - $56,474
$59,547 - $60,582
$60,583 - $61,617
$61,618 - $62,653
$62,654 - $63,688
$63,689 - $64,724
$67,137 - $68,304
$68,305 - $69,471
$69,472 - $70,639
$70,640 - $71,806
$71,807 - $72,974
$74,727 - $76,026
$76,027 - $77,325
$77,326 - $78,625
$78,626 - $79,924
$79,925 - $81,224

Signature *

Clear Signature

Please make your signature legible

Date *

I hereby give my permission to agent, agent NPN, as mentioned in this agreement, 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 agent and their affiliates to: View and use the confidential information provided by me in writing, electronically, or by telephone for the purposes of: 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. Providing ongoing account maintenance and enrollment assistance, as necessary. Responding to inquiries from the Marketplace regarding my application. Act as my Agent of Record concerning all matters related to my health insurance. This designation allows the agent and and their affiliates to represent and assist me in all interactions with the health insurance provider. Ensure that my Personally Identifiable Information (PII) is kept private and safe when collecting, storing, and using it for the above purposes. agent and their affiliates commit to not sharing my PII for any purposes other than those explicitly stated in this agreement. I further attest to one or more of the following conditions being true: My income meets the minimum required to qualify for subsidized healthcare under the Federally Facilitated Marketplace. I am a non-smoker and do not use tobacco products. I, or someone in my household, have experienced a qualifying life change in the past 60 days that qualifies for a Special Enrollment Period. I, or someone in my household, either lost qualifying health coverage in the past 60 days or expect to lose coverage in the next 60 days. Scope of Appointment: I appoint an agent, agent NPN, as my representative for up to 10 years for the above mentioned purposes. I grant the parties mentioned to contact me via phone, email, and/or text. Revocation: I understand that my consent remains in effect until I revoke it. I may revoke or modify my consent at any time by contacting an agent at their email.

By submitting this form, I provide my signature expressly consenting to be contacted by a representative of AGENT NAME at the number I have provided. I understand these communications may be made using an automated technology, including but not limited to an auto-dialer. This consent is not required as a condition of purchasing any goods or services. I agree that such calls and messages may be made to assist me in purchasing or obtaining information about health insurance plans, to receive updates, and to be informed about changes to my plan or services as necessary.

Notice: I understand that I may be required to verify the information provided in this attestation.
I must attest that the information I provide is true, including the facts that qualify me for enrollment. I may be required to submit documents that confirm my eligibility based on the conditions I’ve attested to. By signing above, I acknowledge the terms and conditions outlined in this attestation.

Based on the information provided by you, your agent will determine if you qualify and enroll you in $0 insurance through the Affordable Care Act’s premium tax credit benefits!

ONE MORE STEP:

CLICK GREEN BUTTON AND confirm your information!

$0 INSURANCE IS ONE STEP AWAY!

Signature *

Clear Signature

Please make your signature legible

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Checkboxes *

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 I must provide accurate information for eligibility and may need to provide proof. If I’m enrolled in Marketplace coverage and later found to have other qualifying health coverage, my Marketplace plan will be terminated automatically.
I permit the agent and Marketplace to use my income data for 5 years to determine my eligibility for assistance.
I’m not eligible for a premium tax credit if I have other qualifying health coverage.
I must inform the Marketplace if I become eligible for other coverage to avoid repayment of the premium tax credit.
I must file a federal income tax return for this tax year.
If I’m married at the end of the year, I must file a joint income tax return with my spouse.

No one else will be able to claim me as a dependent
I understand, this does not constitute tax advice, and I should consult a tax advisor for tax-related matters.
I consent to receive electronic notices and use electronic signatures during enrollment.
I confirm I’m authorized for the provided phone number and agree to receive marketing calls/messages.
I agree to allowing Agent name, npn and their affiliates to use my information to complete the Marketplace application on my behalf.
I grant permission to agent name, npn and their affiliates to choose a reasonably similar plan to the plan I selected, or the best Zero premium plan if I wasn’t offered a plan at the time of this submission. I understand and consent that the details of the plan I am enrolled in will be emailed to me within 24 hours of enrollment and I agree to respond to this email if I wish to make changes or contact my agent to do so.
I confirm that I have reviewed the plan that I have selected and will contact agent immediately if I would like to make any changes.
I also grant agent name, NPN and their affiliate to renew my plan at the end of this year for next year in the same plan that I am enrolled in so that there is not a lapse in coverage. If my current plan and carrier is not available at zero cost, I authorize Agent name, NPN and their affiliates to choose and enroll me in the best available Zero premium plan for next year. I understand that if carrier or plan changes, I will be contacted and emailed the new carrier and plan details and agree to contact agent if I wish to make any changes.
I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.
I understand and acknowledge the income I provided will be used to determine my eligibility and ultimately my agent will enroll me using this income, if I misrepresent my income, I will be responsible for paying back the premium tax credit provided to me through the affordable care act.
I hereby testify that I have read the entire agreement, and am fully informed of the agreement and implications of my enrollment and utilization of the affordable care act premium tax credit benefits. I understand that the information I provide will be used to complete my enrollment.
To receive a healthcare subsidy and assistance also known as an Advanced Premium Tax Credit (APTC) or Cost Reduction Sharing, you must file taxes for the upcoming year, even if your income is not taxable. By signing and submitting you agree to file taxes.
The federal marketplace keeps track of those requiring assistance. For this to work, individuals must file taxes every year, even if their income is not taxable or their income is below the poverty line. You MUST file taxes even if you don’t owe anything. By signing and submitting you agree to file taxes.