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First Name

Last Name

I attest that I qualify for one of the following Special Enrollment Periods

I am losing coverage before the end of the current month

I have lost coverage within the last 60 days

I was denied Medicaid by my state

I recently moved to a new county or state

Address

City

State

Zip code

Phone

Email

Date of Birth *

Gender

(Social Security Number: OPTIONAL but if you don’t include it on our application you will need to send in proof of citizenship to the Health insurance marketplace within 90 days)

Social Security Number

EMPLOYMENT AND ELIGIBILITY

Most recent job

This INCLUDES income from your spouse or child even if they aren’t on the plan. If W2 income before taxes. If 1099 income after deductions.

Estimated HOUSEHOLD Income for this year.

How many people need insurance? *

1 (Just You)

2

3 or more

Other than yourself, how many other people are on your tax return? (must file jointly if married to qualify)

Taxable household size

SINGLE MEMBER HOUSEHOLD

Do you claim anyone else on your taxes? *

I do not claim anyone else

I include other people (spouse, children, etc.)

2ND PERSON NEEDING INSURANCE

2nd person First Name

2nd person Last Name

2nd person Gender

Male

Female

2nd person's date of birth

(Social Security Number: OPTIONAL but if you don’t include it on our application you will need to send in proof of citizenship to the Health insurance marketplace within 90 days)

2nd persons Social Security Number

2nd Person relationship to 1st person

Do you only include 2 people on your tax return? *

Yes, there are only 2 people in my household

No, there are more people in my household

3RD PERSON NEEDING INSURANCE

3rd person First Name

3rd person Last Name

3rd person Gender

Male

Female

3rd person's date of birth

(Social Security Number: OPTIONAL but if you don’t include it on our application you will need to send in proof of citizenship to the Health insurance marketplace within 90 days)

3rd persons Social Security Number

3rd persons relationship to 1st person

Do you have any more household members to add? *

Yes

No

4TH HOUSEHOLD MEMBER

4th Household Member First Name

4th Household Member Last Name

4th Household Member Date of birth

Do you have any more household members to add? *

Yes

No

5TH HOUSEHOLD MEMBER

5th Household Member First Name

5th Household Member Last Name

5th Household Member Date of birth *

Enter the rest of the names and date(s) of birth *

CONSENT FOR APPLICATION

I grant Advantage1Brokerage, or their designee and agents, a limited power of attorney to enroll me and/or my family in a free health insurance plan through the ACA Marketplace, access my Healthcare.gov account, submit an income verification letter using the provided income, and, if I'm already enrolled, to become my Agent of Record and transition me to a superior plan if available. This authority also extends to automatic enrollment in a plan upon its renewal. *

Yes

No, you have permission to call me

Do you understand that this is a request to ENROLL you in the best FREE health insurance plan available in your area based on your household income, household size and Zip Code? (If you are not eligible for FREE coverage we will reach out to you to discuss alternative options) *

Yes

No

Do you understand that if the plan we enroll you in does not meet your needs you may cancel it at any time or reach out to us to discuss alternative options? *

Yes

No

HealthCare.gov access

Do you give us permission to access your healthcare.gov account if you have one, in order to enroll you in the best plan possible? *

Yes

No

Free Plan Eligibility

Do you understand that plan options vary based on household income, location, age and household size? *

Yes

No

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david@dependablecoverage.co

dependablecoverage.co

Broussard, LA

Licensed In Several States

Broussard, LA

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