Online Application

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The Affordable Health For Texas Insurance Company, respects your privacy, and we want you to understand how we may collect personal information about you through our online Application and how that information may be used, maintained and, in some cases, shared with Marketplace Organization, a federal government health insurance provider through www.healthcare.gov.

This privacy policy (“Privacy Policy”) sets forth the privacy practices and policies governing our online Applications and Company's email addresses: "admin@healthfortexas.com".

“Personal information”, is any information that enables Marketplace to identify you, directly or indirectly, by reference to an identifier such as your name, identification number, location data, online identifier or one or more factors specific to you. Personal information includes “personal information such as: Social Security Number, Current Immigratio Status,DOB, Annual Household Incomes and Tax Returns”, and “pseudonymised personal information” but excludes anonymous information or information that has had the identity of an individual permanently removed.

BY USING OR ACCESSING OUR ONLINE APPLICATION OR BY PROVIDING PERSONAL INFORMATION TO US ON OR THROUGH THESE APPLICATIONS AND EMAILS, YOU CONSENT TO THE COLLECTION, USE, TRANSFER AND DISCLOSURE OF THAT INFORMATION IN ACCORDANCE WITH THIS PRIVACY POLICY AND APPLICABLE LAW.

Online Application

Main
First Name:*
Last Name:*
Middle Name:
Email address:*
Phone Number:*
Date of Brith:*
Example: mm/dd/yyyy
Sex:*
YesNo

Social Security Number:*
YesNo
Provide your full name as appears on your Social Security Card.*
Residential address:*
APT / Suite # :
City:*
Other City:*
State:*
Zip code:*
County*
Other County:*
NoYes
Provide your mailing address*
Are You Latino?*
Other Latino:*
Race:*
Other Race:*

Provide your immigration status:*

US CITIZEN

Enter your certificate info
Green Card

Enter your card info
Employment authorization

Enter your employment authorization info
Machine Readable (temprory I-551 language)
Arrival/Departure (I-94, I-94A)
Nonimmigrant (F-1,F-2) Student Status (I-20)
Refugee Travel Document (I-571)
Notice of Action (I-797)
Exchange visitor (J-1,J-2)
Certificate #*
Card #*
USCIS #*
A#*
Category:*
SEVIS ID #*
I-94 #*
Passport #*
Issued by *
Passport Exp Date:*
Example: mm/dd/yyyy
Exp Date:*
Example: mm/dd/yyyy
Upload Your Documents*

Browse Files

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Current Job & Income Information
Job Status :*

Employer / First Job this year
First Employer Name :*
First Employer Phone Number :*
First Job Monthly Wages/Salary /Tips *
Before any deductions
When did you start your first job?*
Example: mm/dd/yyyy
YesNo
When did your first current job end?*
Example: mm/dd/yyyy
YesNo
YesNo
YesNo

Employer / Second Job
Second Employer Name :*
Second Employer Phone Number :*
Second Job Monthly Wages/Salary /Tips *
Before any deductions
When did you start your second job?*
Example: mm/dd/yyyy
YesNo
When did your second job end?*
Example: mm/dd/yyyy
YesNo
YesNo

Self-Employment
Type of Work?*
How much is your Monthly Net Income? *
Total Gross income minus Total business expenses = Net Income
When did you start your bussines?*
Example: mm/dd/yyyy
YesNo

Other Income
Please provide your other source of income:*
Other Source:
How much do you receive from your other source of income?*
Monthly
When did you start receiving the other income?*
Example: mm/dd/yyyy

The following questions are regarding your total household income and expenses. Please upload the following accepted documents to proof the family’s annual income:

1. Proof of last year Tax Return

2. The last 2 pay stubs from your job

3. W-2 or 1099 from your Employer

4. Letter from the Employer stating your duties and annual income

5. A signed letter written by the applicant or spouse in regards to the type of work and their total annual income
Upload Documents

Browse Files

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Expenses
YesNo
How much is your monthly student loan interest? *
YesNo
How much is the monthly cost of your Tuition and Books? *
The maximum amount that you can claim as your Tuition/Books, it’s up to $2,000 per only year

Insurance Status:
Do you have any health insurance coverage through the following sources?*
Yes, I do.No, I already have coverageI don’t need any coverage
YesNo
When did your Medicaid or CHIP got terminated?*
Example: mm/dd/yyyy
YesNo

Marital Status:
SingleMarriedSingle with dependents
How many dependents do you have? (please don’t include your spouse)*

Spouse

Enter your spouse informations
First Name:*
Last Name:*
Middle Name:
Email address:
Phone Number:
Date of Brith:*
Example: mm/dd/yyyy
Sex:*
YesNo
Social Security Number:*
YesNo
Provide your full name as appears on your Social Security Card.*
Are You Latino?*
Other Latino:*
Race:*
Other race:*

Provide your immigration status:*

US citizen

Enter your certificate info
Green Card

Enter your card info
Employment authorization

Enter your employment authorization info
Machine Readable (temprory I-551 language)
Arrival/Departure (I-94, I-94A)
Nonimmigrant (F-1,F-2) Student Status (I-20)
Refugee Travel Document (I-571)
Notice of Action (I-797)
Exchange visitor (J-1,J-2)
Certificate #:*
Card #*
USCIS #*
A#*
Category:*
SEVIS ID #*
I-94 #*
Passport #*
Issued by *
Passport Exp Date:*
Example: mm/dd/yyyy
Exp Date:*
Example: mm/dd/yyyy
Upload Your Documents*

Browse Files

Cancelof

Current job & income information
Job Status :*

Employer / First current Job
First current Employer Name :*
First current Employer Phone Number :*
First current Job Monthly Wages/Salary /Tips*
Before any deductions
When did you start your first current job?*
Example: mm/dd/yyyy
YesNo
When did your first current job ended?*
Example: mm/dd/yyyy
YesNo
YesNo
YesNo

Employer / Second current Job
Second current Employer Name :*
Second current Employer Phone Number :*
Second current Job Monthly Wages/Salary /Tips *
Before any deductions
When did you start your second current job?*
Example: mm/dd/yyyy
YesNo
When did your second current job ended?*
Example: mm/dd/yyyy
YesNo
YesNo

Self-Employed
Type of Work?*
How much is your Monthly Net Income?*
Total Gross income minus Total business expenses = Net Income
When did you start your bussines?*
Example: mm/dd/yyyy
YesNo

Other Income
Please provide your other source of income:*
Other Source:
How much do you receive from your other source of income?*
Monthly
When did you start to receive your other income?*
Example: mm/dd/yyyy

The following questions are regarding your total household income and expenses. Please upload the following accepted documents to proof the family’s annual income:

1. Proof of last year Tax Return

2. The last 2 pay stubs from your job

3. W-2 or 1099 from your Employer

4. Letter from the Employer stating your duties and annual income

5. A signed letter written by the applicant or spouse in regards to the type of work and their total annual income
Upload Documents

Browse Files

Cancelof

Expenses
YesNo
How much is your monthly student loan interest?*
YesNo
How much is your monthly Tuition and Books?*
The maximum amountthat you can claim as your Tuition/Books, it’s up to $2,000 per only year

Do you have any health insurance coverage through the following sources?*
Yes, I do.No, I already have coverageI don’t need any coverage
YesNo
When did your Medicaid or CHIP was denied?*
Example: mm/dd/yyyy
YesNo

YesNo

First Dependent

Enter your dependent information
Relationship*
Other Relationship:*
First Name:*
Last Name:*
Middle Name:
Email address:
Phone Number:
Date of Brith:*
Example: mm/dd/yyyy
Sex:*
YesNo
Social Security Number:*
YesNo
Provide your full name as appears on your Social Security Card.*
Are You Latino?*
Other Latino:*
Race:*
Other Race:*

Provide your immigration status:*

US citizen

Enter your certificate info
Green Card

Enter your card info
Employment authorization

Enter your employment authorization info
Machine Readable (temprory I-551 language)
Arrival/Departure (I-94, I-94A)
Nonimmigrant (F-1,F-2) Student Status (I-20)
Refugee Travel Document (I-571)
Notice of Action (I-797)
Exchange visitor (J-1,J-2)
Certificate #:*
Card #*
USCIS #*
A#*
Category:*
SEVIS ID #*
I-94 #*
Passport #*
Issued by *
Passport Exp Date:*
Example: mm/dd/yyyy
Exp Date:*
Example: mm/dd/yyyy
Upload Your Documents*

Browse Files

Cancelof

Current job & income information
Job Status :*

Employer / First current Job
First current Employer Name :*
First current Employer Phone Number :*
First current Job Monthly Wages/Salary /Tips*
Before any deductions
When did you start your first job?*
Example: mm/dd/yyyy
YesNo
When did your first job ended?*
Example: mm/dd/yyyy
YesNo
YesNo
YesNo

Employer / Second current Job
Second current Employer Name :*
Second current Employer Phone Number :*
Second current Job Monthly Wages/Salary /Tips*
Before any deductions
When did you start your second current job?*
Example: mm/dd/yyyy
YesNo
When did your second current job ended?*
Example: mm/dd/yyyy
YesNo
YesNo

Self-Employed
Type of Work?*
How much is your MONTLY Net Income?*
Total Gross income minus Total business expenses = Net Income
When did you start your bussines?*
Example: mm/dd/yyyy
YesNo

Other Income
Please provide your other source of income:*
Other Source:*
How much do you receive from your other source of income?*
Monthly
When did you start receiving the other income?*
Example: mm/dd/yyyy

The following questions are regarding your total household income and expenses. Please upload the following accepted documents to proof the family’s annual income:

1.Proof of last year Tax Return

2.The last 2 pay stubs from your job

3.W-2 or 1099 from your Employer

4.Letter from the Employer stating your duties and annual income

5.A signed letter written by the applicant or spouse in regards to the type of work and their total annual income
Upload Documents

Browse Files

Cancelof

Expenses
YesNo
How much is your monthly student loan interest? *
YesNo
How much is the monthly cost of your Tuition and Books?*
The maximum amountthat you can claim as your Tuition/Books, it’s up to $2,000 per only year

Do you have any health insurance coverage through the following sources?*
Yes, I do.No, I already have coverageI don’t need any coverage
YesNo
When did your Medicaid or CHIP was denied?*
Example: 07/12/2020
YesNo
YesNO

Second Dependent

Enter your dependent information
Relationship*
Other Relationship:*
First Name:*
Last Name:*
Middle Name:
Email address:
Phone Number:
Date of Brith:*
Example: mm/dd/yyyy
Sex:*
YesNo
Social Security Number:*
YesNo
Provide your full name as appears on your Social Security Card.*
Are You Latino?*
Other Latino:*
Race:*
Other Race:*

Provide your immigration status:*

US citizen

Enter your certificate info
Green Card

Enter your card info
Employment authorization

Enter your employment authorization info
Machine Readable (temprory I-551 language)
Arrival/Departure (I-94, I-94A)
Nonimmigrant (F-1,F-2) Student Status (I-20)
Refugee Travel Document (I-571)
Notice of Action (I-797)
Exchange visitor (J-1,J-2)
Certificate #:*
Card #*
USCIS #*
A#*
Category:*
SEVIS ID #*
I-94 #*
Passport #*
Issued by *
Passport Exp Date:*
Example: mm/dd/yyyy
Exp Date:*
Example: mm/dd/yyyy
Upload Your Documents*

Browse Files

Cancelof

Current job & income information
Job Status :*

Employer / First current Job
First current Employer Name :*
First current Employer Phone Number :*
First current Job Monthly Wages/Salary /Tips*
Before any deductions
When did you start your first current job?*
Example: mm/dd/yyyy
YesNo
When did your first job ended?*
Example: mm/dd/yyyy
YesNo
YesNo
YesNo

Employer / Second current Job
Second current Employer Name :*
Second current Employer Phone Number :*
Second current Job Monthly Wages/Salary /Tips*
Before any deductions
When did you start your second current job?*
Example: mm/dd/yyyy
YesNo
When did your second current job ended?*
Example: mm/dd/yyyy
YesNo
YesNo

Self-Employed
Type of Work?*
How much is your Monthly Net Income? *
Total Gross income minus Total business expenses = Net Income
When did you start your bussines?*
Example: mm/dd/yyyy
YesNo

Other Income
Please provide your other source of income:*
Other Income:*
How much do you receive from your other source of income?*
Monthly
When did you start receiving the other income?*
Example: mm/dd/yyyy

The following questions are regarding your total household income and expenses. Please upload the following accepted documents to proof the family’s annual income:

1.Proof of last year Tax Return

2.The last 2 pay stubs from your job

3.W-2 or 1099 from your Employer

4.Letter from the Employer stating your duties and annual income

5.A signed letter written by the applicant or spouse in regards to the type of work and their total annual income
Upload Documents

Browse Files

Cancelof

Expenses
YesNo
How much is your monthly student loan interest? *
Monthly
YesNo
How much is the monthly cost of your Tuition and Books? *
The maximum amount that you can claim as your Tuition/Books, it’s up to $2,000 per only year

Do you have any health insurance coverage through the following sources?*
Yes, I do.No, I already have coverageI don’t need any coverage
YesNo
When did your Medicaid or CHIP was denied?*
Example: mm/dd/yyyy
YesNo
YesNo

3rd Dependent

Enter your dependent information
Relationship*
Other Relationship:*
First Name:*
Last Name:*
Middle Name:
Email address:
Phone Number:
Date of Brith:*
Example: mm/dd/yyyy
Sex:*
YesNo
Social Security Number:*
YesNo
Provide your full name as appears on your Social Security Card.*
Are You Latino?*
Other Latino:*
Race:*
Other Race:*

Provide your immigration status:*

US citizen

Enter your certificate info
Green Card

Enter your card info
Employment authorization

Enter your employment authorization info
Machine Readable (temprory I-551 language)
Arrival/Departure (I-94, I-94A)
Nonimmigrant (F-1,F-2) Student Status (I-20)
Refugee Travel Document (I-571)
Notice of Action (I-797)
Exchange visitor (J-1,J-2)
Certificate #:*
Card #*
USCIS #*
A#*
Category:*
SEVIS ID #*
I-94 #*
Passport #*
Issued by *
Passport Exp Date:*
Example: mm/dd/yyyy
Exp Date:*
Example: mm/dd/yyyy
Upload Your Documents*

Browse Files

Cancelof

Current job & income information
Job Status :*

Employer / First current Job
First current Employer Name :*
First current Employer Phone Number :*
First current Job Monthly Wages/Salary /Tips*
Before any deductions
When did you start your first current job?*
Example: mm/dd/yyyy
YesNo
When did your first job ended?*
Example: mm/dd/yyyy
YesNo
YesNo
YesNo

Employer / Second current Job
Second current Employer Name :*
Second current Employer Phone Number :*
Second current Job Monthly Wages/Salary /Tips*
Before any deductions
When did you start your second current job?*
Example: mm/dd/yyyy
YesNo
When did your second current job ended?*
Example: mm/dd/yyyy
YesNo
YesNo

Self-Employed
Type of Work?*
How much is your Monthly Net Income? *
Total Gross income minus Total business expenses = Net Income
When did you start your bussines?*
Example: mm/dd/yyyy
YesNo

Other Income
Please provide your other source of income:*
Other Income:*
How much do you receive from your other source of income?*
Monthly
When did you start receiving the other income?*
Example: mm/dd/yyyy

The following questions are regarding your total household income and expenses. Please upload the following accepted documents to proof the family’s annual income:

1.Proof of last year Tax Return

2.The last 2 pay stubs from your job

3.W-2 or 1099 from your Employer

4.Letter from the Employer stating your duties and annual income

5.A signed letter written by the applicant or spouse in regards to the type of work and their total annual income
Upload Documents

Browse Files

Cancelof

Expenses
YesNo
How much is your monthly student loan interest? *
Monthly
YesNo
How much is the monthly cost of your Tuition and Books? *
The maximum amount that you can claim as your Tuition/Books, it’s up to $2,000 per only year

Do you have any health insurance coverage through the following sources?*
Yes, I do.No, I already have coverageI don’t need any coverage
YesNo
When did your Medicaid or CHIP was denied?*
Example: mm/dd/yyyy
YesNo
YesNo

4th Dependent

Enter your dependent information
Relationship*
Other Relationship:*
First Name:*
Last Name:*
Middle Name:
Email address:
Phone Number:
Date of Brith:*
Example: mm/dd/yyyy
Sex:*
YesNo
Social Security Number:*
YesNo
Provide your full name as appears on your Social Security Card.*
Are You Latino?*
Other Latino:*
Race:*
Other Race:*

Provide your immigration status:*

US citizen

Enter your certificate info
Green Card

Enter your card info
Employment authorization

Enter your employment authorization info
Machine Readable (temprory I-551 language)
Arrival/Departure (I-94, I-94A)
Nonimmigrant (F-1,F-2) Student Status (I-20)
Refugee Travel Document (I-571)
Notice of Action (I-797)
Exchange visitor (J-1,J-2)
Certificate #:*
Card #*
USCIS #*
A#*
Category:*
SEVIS ID #*
I-94 #*
Passport #*
Issued by *
Passport Exp Date:*
Example: mm/dd/yyyy
Exp Date:*
Example: mm/dd/yyyy
Upload Your Documents*

Browse Files

Cancelof

Current job & income information
Job Status :*

Employer / First current Job
First current Employer Name :*
First current Employer Phone Number :*
First current Job Monthly Wages/Salary /Tips*
Before any deductions
When did you start your first current job?*
Example: mm/dd/yyyy
YesNo
When did your first job ended?*
Example: mm/dd/yyyy
YesNo
YesNo
YesNo

Employer / Second current Job
Second current Employer Name :*
Second current Employer Phone Number :*
Second current Job Monthly Wages/Salary /Tips*
Before any deductions
When did you start your second current job?*
Example: mm/dd/yyyy
YesNo
When did your second current job ended?*
Example: mm/dd/yyyy
YesNo
YesNo

Self-Employed
Type of Work?*
How much is your Monthly Net Income? *
Total Gross income minus Total business expenses = Net Income
When did you start your bussines?*
Example: mm/dd/yyyy
YesNo

Other Income
Please provide your other source of income:*
Other Income:*
How much do you receive from your other source of income?*
Monthly
When did you start receiving the other income?*
Example: mm/dd/yyyy

The following questions are regarding your total household income and expenses. Please upload the following accepted documents to proof the family’s annual income:

1.Proof of last year Tax Return

2.The last 2 pay stubs from your job

3.W-2 or 1099 from your Employer

4.Letter from the Employer stating your duties and annual income

5.A signed letter written by the applicant or spouse in regards to the type of work and their total annual income
Upload Documents

Browse Files

Cancelof

Expenses
YesNo
How much is your monthly student loan interest? *
Monthly
YesNo
How much is the monthly cost of your Tuition and Books? *
The maximum amount that you can claim as your Tuition/Books, it’s up to $2,000 per only year

Do you have any health insurance coverage through the following sources?*
Yes, I do.No, I already have coverageI don’t need any coverage
YesNo
When did your Medicaid or CHIP was denied?*
Example: mm/dd/yyyy
YesNo
YesNo

Select Your Health Insurance Plan
GoldSilverBronze
Name of the Plan:

Signature
Sign your name here *
Date*
Example: mm/dd/yyyy

EmailTextby Mail
Email address
Phone number
Mailing address

Date

MonthDayYear
DateHourMinutesAM/PM Option
Rate Online Application
Should be Empty:

Online Application

US CITIZEN

Green Card

Employment authorization

Machine Readable (temprory I-551 language)

Arrival/Departure (I-94, I-94A)

Nonimmigrant (F-1,F-2) Student Status (I-20)

Refugee Travel Document (I-571)

Notice of Action (I-797)

Exchange visitor (J-1,J-2)

Current Job & Income Information

Employer / First Job this year

Employer / Second Job

Self-Employment

Other Income

Expenses

Insurance Status:

Marital Status:

Spouse

US citizen

Green Card

Employment authorization

Machine Readable (temprory I-551 language)

Arrival/Departure (I-94, I-94A)

Nonimmigrant (F-1,F-2) Student Status (I-20)

Refugee Travel Document (I-571)

Notice of Action (I-797)

Exchange visitor (J-1,J-2)

Current job & income information

Employer / First current Job

Employer / Second current Job

Self-Employed

Other Income

Expenses

First Dependent

US citizen

Green Card

Employment authorization

Machine Readable (temprory I-551 language)

Arrival/Departure (I-94, I-94A)

Nonimmigrant (F-1,F-2) Student Status (I-20)

Refugee Travel Document (I-571)

Notice of Action (I-797)

Exchange visitor (J-1,J-2)

Current job & income information

Employer / First current Job

Employer / Second current Job

Self-Employed

Other Income

Expenses

Second Dependent

US citizen

Green Card

Employment authorization

Machine Readable (temprory I-551 language)

Arrival/Departure (I-94, I-94A)

Nonimmigrant (F-1,F-2) Student Status (I-20)

Refugee Travel Document (I-571)

Notice of Action (I-797)

Exchange visitor (J-1,J-2)

Current job & income information

Employer / First current Job

Employer / Second current Job

Self-Employed

Other Income

Expenses

3rd Dependent

US citizen

Green Card

Employment authorization

Machine Readable (temprory I-551 language)

Arrival/Departure (I-94, I-94A)

Nonimmigrant (F-1,F-2) Student Status (I-20)

Refugee Travel Document (I-571)

Notice of Action (I-797)

Exchange visitor (J-1,J-2)

Current job & income information

Employer / First current Job

Employer / Second current Job

Self-Employed