Answer the Following Questions Accurately to Authorize Your Application!

First Name *

Last Name *

Email *

Cell Phone *

Are you applying for yourself? *

Yes

What is the address where the insurance cards can be mailed?

Mailing Address *

City *

State *

Postal code *

County *

Primary Applicant's Date of Birth MM-DD-YYYY *

Primary Applicant's Social Security Number *

Sex *

Male

Female

Do You Have A Spouse? *

Yes

Spouse Legal First Name

Spouse Legal Last Name

Spouse's Gender

Spouse's Date of Birth MM-DD-YYYY

Spouse's Social Security Number

Do You Have Any Dependents that you will claim on your taxes? *

Yes

Dependent 1 Full Legal Name

Dependent 1 Gender

Dependent 1 Date of Birth MM-DD-YYYY

Dependent 1 Social Security Number v3

Do You Have a 2nd Dependent?

Yes

Dependent 2 Full Legal Name

Dependent 2 Gender

Dependent 2 Date of Birth MM-DD-YYYY

Dependent 2 Social Security Number v3

Do You Have a 3rd Dependent?

Yes

Dependent 3 Full Legal Name

Dependent 3 Date of Birth MM-DD-YYYY

Dependent 3 Gender

Dependent 3 Social Security Number v3

Do You Have a 4th Dependent?

Yes

Dependent 4 Full Legal Name

Dependent 4 Gender

Dependent 4 Date of Birth MM-DD-YYYY

Dependent 4 Social Security Number v3

Do You Have a 5th Dependent?

Yes

Dependent 5 Full Legal Name

Dependent 5 Gender

Dependent 5 Date of Birth MM-DD-YYYY

Dependent 5 Social Security Number v3

Employment Status *

Employed

Self-employed

Unemployed

Do you plan to file taxes for this current year?

Yes

What status will you use when filing taxes for this year? *

What will Your "ESTIMATED" Annual Income be for this year? *

Do you or anyone in your household applying for coverage have Medicare, Medicaid or VA 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 hello@earlenebacon.com.

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

YES, let's find the best health insurance plan I can qualify for.

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