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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

No

Current employment situation *

Employed

Unemployed

Receiving Social Security

Other income

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? *

Yes

No

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

No

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

No

Dependent 3 Full Legal Name *

Dependent 3 Gender *

Dependent 3 Date of Birth MM-DD-YYYY *

Dependent 3 Social Security Number v3 *

Do You Have a 4th Dependent?

Yes

No

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

No

Dependent 5 Full Legal Name *

Dependent 5 Gender *

Dependent 5 Date of Birth MM-DD-YYYY *

Dependent 5 Social Security Number v3 *

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 [email protected].

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

Projected Income 2024 *

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. *

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