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AFFORDABLE AMERICAN

HEALTH CARE

Get NEW Subsidized MarketPlace

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications.

One of our Marketplace Specialists will Process your application to get you the best coverage possible

First Name

Last Name

Date of birth

Male or Female

M

F

Have you used tobacco 4 or more times a week for the past 6 months?

YES

NO

Phone *

Email *

Address *

City *

State *

Postal code *

Marital Status *

Single

Married

Divorced

Widowed

Spouse's Name

Spouse's DOB

Has your spouse used tobacco 4 or more times a week for the past 6 months?

Yes

No

Spouse's Employment

Employed

Self-Employed

Social Security Benefits

Unemployed

Estimated Monthly Income* PLEASE INCLUDE EVEN IF YOU DO NOT WANT THEM ON YOUR HEALTH INSURANCE POLICY

Do you want your spouse covered on this policy?

Yes

No

Spouse's Social Security #?

Your Employment Information *

Employed

Unemployed

Receiving Social Security

Employer Name

Estimated Monthly Income

SSI Monthly Income *

Are you claiming any dependents on your taxes?

Yes

No

Child's Full Name *

Child's DOB *

Child's SSN *

if there are multiple dependents, please list additional information here

Doctor's Full Name

Doctor's City

In Order to get a Cost Sharing Reduction and an Advanced Premium Tax Credit you will need to file a tax return for the upcoming year. Will you file a tax return for the coming year?

Yes

No

What is your social security #? *

Agent/Broker Consent *

By Clicking this box,I give my permission to Gabriel Brooks NPN 17966188 to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: Searching for an existing Marketplace application; Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums; Providing ongoing account maintenance and enrollment assistance, as necessary; or Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the Gabriel Brooks NPN 17966188 will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting Gabriel Brooks NPN 17966188 at anytime. You also attest that all of the information is true and correct to the best of your knowledge. You are also giving Gabriel Brooks NPN 17966188 the permission to process your application with the information given to us.

Signature *

Clear

Get NEW Subsidized MarketPlace

ACA Now!

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications. One of our Marketplace Specialists will Process your application to get you the best coverage possible

AFFORDABLE AMERICAN

HEALTH CARE

Get NEW Subsidized MarketPlace

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications.

Get NEW Subsidized MarketPlace

ACA Now!

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications. One of our Marketplace Specialists will Process your application to get you the best coverage possible

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