Answer the Following Questions Accurately to Authorize Your Application!

Do you have insurance through your employer, Medicare or VA? *

Yes

Are you currently employed? *

Yes

Employer Name *

Gender *

Male

Female

First Name *

Last Name *

Street Address *

City *

State *

Zip/Postal code *

Phone *

Email *

Primary Applicant's Social Security Number *

Primary Date of Birth MM-DD-YYYY *

Do You Have Any Dependents? *

Yes

Dependent 1 Full Legal Name *

Dependent 1 Gender *

Dependent 1 Date of Birth MM-DD-YYYY *

Do You Have a 2nd Dependent? *

Yes

Dependent 2 Full Legal Name *

Dependent 2 Gender *

Dependent 2 Date of Birth MM-DD-YYYY *

Do You Have a 3rd Dependent? *

Yes

Dependent 3 Full Legal Name *

Dependent 3 Gender *

Dependent 3 Date of Birth MM-DD-YYYY *

Do You Have a 4th Dependent? *

Yes

Dependent 4 Full Legal Name *

Dependent 4 Gender *

Dependent 4 Date of Birth MM-DD-YYYY *

Do You Have a 5th Dependent? *

Yes

Dependent 5 Full Legal Name *

Dependent 5 Gender *

Dependent 5 Date of Birth MM-DD-YYYY *

Expected Income Per Month *

Please Be Accurate – Income will be Verified by ACA At Year End

Do you authorize us to submit your Major Medical application to the Marketplace? *

Yes

Do you give us permission to update your policy throughout the year if needed? *

Yes

Marketplace consent

Do we have your permission to automatically re-enroll you in your plan in the future or automatically enroll you in a similar plan if your plan does not renew in the future so you won’t lose coverage? *

Yes

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"

Authorization Date *

Authorization Signature - I authorize you to be my Agent of Record each month until I revoke consent and re-enroll me in the best plan during Open Enrollment if my current plan is discontinued. *

Clear

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