Health Insurance
Insurance Professionals of GA
Who referred you? Or how did you hear about us?
Christina
Tawanda
Chelsea
Lisa
Sherita Smith
Veanna Mumuni
Other
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security Number (SSN)
*
Date of Birth
*
-
Month
-
Day
Year
Date
Do you plan on filing taxes for the year 2025? (you must have income to qualify for a credit)
*
Yes
No
What is the estimated household income you will make after all deductions in 2025?
*
Enter Amount in $
How many people/dependents will you file on your taxes in 2025?
*
Name, Date of Birth, SSN# for each person that you will file on your 2025 taxes? Only need SSN# if they are applying coverage for 2025
Rows
Name of Dependent
Social Security #
Date of Birth
Enter
Enter
Enter
Enter
Enter
Employment Information
Employer Name
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Monthly Income
Enter amount in $
Are you interested in Life Insurance?
*
Yes
No
Are you interested in Dental Insurance?
*
Yes
No
Are you interested in Vision Insurance?
*
Yes
No
Consent
Please review and accept the consent below. By signing below l give my permission to__ INSURANCE PROFESSIONALS OF GA LLC [name of the person or entity who has the consumer's consent]Christina Battle (“Agent”) 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, | authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by phone only for 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 ® Responding to inquiries from the Marketplace regarding my application | understand that the Agent will not use or share my personally identifiable information (Pll) for any purposes other than those listed above. The Agent will ensure that my Pll is kept private and safe when collecting, storing, and using my Pll for the stated purposes above. e | confirm that the information | provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. | understand that | 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. | understand that my consent remains in effect until | revoke it, and | may revoke or modify my consent at any time by contacting my Agent. Primary Writing Agent: Christina Battle NPN: 7658400
Consent Agreement
*
Primary applicant signature:
*
Submit- Thank you! An Agent will be in contact with you within 1 business Day!
Should be Empty: