Answer the Following Questions Accurately to Authorize Your Application!
Please only submit this application if you are not enrolled in an ACA plan for 2024.

First Name

Last Name

Cell Phone

What is your address where we can mail the cards?

Street Address

City

State

Postal code

Primary Date of Birth MM-DD-YYYY

Primary Applicant's Social Security Number

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

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

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