Answer the Following Questions Accurately to Authorize Your Application!

Select your frist dependent's gender
Select your second dependent's gender
Select your third dependent's gender
Select your fourth dependent's gender
Select your fifth dependent's gender
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Please Be Accurate – Income will be Verified by ACA At Year End

Marketplace consent

1. Search for an existing Marketplace Plan; 2. Complete an application for eligibility and enrollment in a Marketplace Plan; 3. Provide ongoing maintenance and enrollment assistance; or 4. Respond to inquiries from the Marketplace regarding my application.

I confirm what I have shared is accurate and true for entry on my Marketplace Health Insurance Application, that I have read and consent with the terms and understand the above mentioned agent will safely store and use my personal identifiable information for the above stated purposes, and by submitting this document I agree that my household income falls within the chart below, that I do not have Medicare/Medicaid/Employer Coverage, and I do not use tobacco products, qualifying myself for Zero Premium Health Coverage. I understand my consent remains until I revoke it by emailing dave@safeharborinsuranceagency.com.

By providing your mobile number, you consent to receive SMS communications from ZZ David Evans. I can opt out of texts any time by replying "STOP"

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.