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Marketplace Consumer Data Collection and Consent Form
This is an internal document we use to determine eligibility and/or enroll clients into a Marketplace Health Plan. Your information will only be used for this purpose. Any other use is strictly prohibited. Please fill out all sections that apply to you. Fields that have a red asterix * are required to complete the form. Once the form has been completed an Agent will review your application and call you if any other information is required or to discuss available options. Use of an Agent is recommended as the Marketplace changes every year. We make sure you have the most up to date information and that the plan you enroll into is the best fit for your health needs as well as budget.
Plan Name
Please Select
Bronze 4
Silver 14
Silver 7
Other (see Note)
if you have a plan in mind select here
Plan Premium
leave blank unless you have used our qote tool
MKTR CODE / AGENT CODE
*
Please Select
XTREME
Agent Only Field
Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number Home
*
Please enter a valid phone number.
Phone Number Cell
Please enter a valid phone number.
Email
*
example@example.com
Tobacco Use?
*
Yes
No
Gender
*
Male
Female
N/A
US Citizen?
*
Yes
No
Marital Status?
*
Single
Married
Are you an American Indian or Alaska native?
Yes
No
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
*
Please ask for county
Spouse's Information
(if applicable)
Name
First Name
Middle Name
Last Name
SSN
Please enter a Social Security Number.
Date of Birth
-
Month
-
Day
Year
Date
Phone Number Home
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Email
example@example.com
Gender?
Male
Female
N/A
US Citizen?
Yes
No
Tobacco Us?
Yes
No
Marital Status?
Single
Married
Dependents
Dependent 1
Dependent 2
Dependent 3
First Name
Last Name
SSN
Date of Birth
Age
Needs Coverage
Gender
On Medicaid
Does everyone listed live at the above address?
Yes
No
If Not, Who / Address
Was anyone in Foster Care?
Yes
No
Please answer all questions below:
Who uses Tobacco?
Last use?
Is anyone on Medicaid? Please list:
Did you file taxes last year?
Yes
No
Will you file this year?
Yes
No
Have you reconciled Tax credits in the past? What years?
If married, will you file your income taxes jointly?
Yes
No
Does your spouse have insurance offered where they work?
Yes
No
Employer Name
*
Employer's Phone Number
*
Please enter a valid phone number.
Expected Annual Income
*
Must have Income
Spouse's Employer Name
Employer's Phone Number
Please enter a valid phone number.
Expected Annual Income
Are you a full time student?
Yes
NO
Other earnings:
Notes:
Other Documents
ID Type
Drivers License
Passport
Social Security Card
Green Card
Proof of Income
Non Immigrant Work Visa
Are you a naturalized or derived citizen?
Yes
No
File Upload
Browse Files
Drag and drop files here
Choose a file
Tap to use camera to take a photo of document(s) and upload
Cancel
of
Name
*
First Name
Last Name
Signature
*
SSN
*
Please enter a valid Social Security Number.
Date
*
-
Month
-
Day
Year
Date
click here to submit
Should be Empty: