AFFORDABLE HEALTHCARE ENROLLMENT

AFFORDABLE HEALTHCARE ENROLLMENT
Enrollment in the Marketplace offers you health insurance choices if you qualify. To determine if you qualify for a tax credit, the Marketplace will retrieve your past year W2's and an Experian report to confirm your identity. Please call 334.492.2486 to let us know you have completed your application.
Phone Number
Please enter a valid phone number.
BEST TIME TO CALL
Name

First NameLast Name
DOB
SSN#
ADDRESS
COUNTY
State
City
Zip
Email
example@example.com
do you file a tax return?
do you file a tax return?
Have you smoked last six months?

YesNo
US Citizen?

YesNo
Does your employer provide you health insurance?

YesNo
Spouse
DOB
SSN#
ADDRESS
COUNTY
City
State
Zip
Email
example@example.com
Does your employer provide you health insurance?

YesNo
US Citizen

YesNo
do you file a tax return?
Have you smoked last six months?

YesNo
How many people live in your household?
Your AGI
SECURITY QUESTIONS
1. City your mother born?
2. Favorite radio station
3. Grandmother nickname
4. City your first job
5. Your high school
OTHER INCOME
Employer
Income
Phone
Phone Number
Please enter a valid phone number.
Employer
Income
Phone
Self Employed ( Includes 1099 Income)
Unemployed
SSI
Bus, Name
Pension
Alimony
DEPEN/AGE | INS/DOB | Gnd/Sex | Social Security
NAME
Y/N DOB
M/F-S/D SSN#
NAME
Y/N DOB
M/F-S/D SSN#
NAME
Y/N DOB
M/F-S/D SSN#
NAME
Y/N DOB
M/F-S/D SSN#
FOR AGENT USE ONLY
MarketPlace login
MarketPlace password
New Email Login
example@example.com
New Email password
Type of Plan
Monthly Premium
Tax Credit $
Application #
Return to agent ELON MIREE ( NPN 7646801) OFFICE (334)651.0196

Email: ELONMIREE@GMAIL.COM FAX (678) 401-0228
SUMMARY REPORT
DATE

MonthDayYear
Date
CRS
AGENT ELON MIREE/NPN 7646801 MAKE SURE YOU GIVE TO MARKETPLACE TO PUT ON APPLICATION AND FILE FOR 1YR UNLIMITED ACCESS.
NAME ON CARD: CARD NUMBER VISA, MASTERCARD, DISCOVER
RT#
ACCT #
Notes Dates: AGENT MUST INITIAL WHEN ENTERING A NOTE
File Upload-W2's, 1099, Driver's License , Social Security Card, etc.

Cancelof
Date

MonthDayYear
Date
Should be Empty:

AFFORDABLE HEALTHCARE ENROLLMENT

SECURITY QUESTIONS

OTHER INCOME

DEPEN/AGE | INS/DOB | Gnd/Sex | Social Security

FOR AGENT USE ONLY

SUMMARY REPORT

AGENT ELON MIREE/NPN 7646801 MAKE SURE YOU GIVE TO MARKETPLACE TO PUT ON APPLICATION AND FILE FOR 1YR UNLIMITED ACCESS.

NAME ON CARD: CARD NUMBER VISA, MASTERCARD, DISCOVER