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 (Date of Birth)
SSN# (Social Security Number)
ADDRESS
COUNTY(The County you live in)
State
City
Zip
Email
example@example.com
do you file a tax return this year? (Yes or No)
YesNo
YesNo
YesNo
Spouse (Is your spouse on your income tax return) If not skip the next 13 steps, go to the AGI line
DOB
SSN#
ADDRESS
COUNTY
City
State
Zip
Email
example@example.com
YesNo
YesNo
do you file a tax return?
YesNo
How many people live in your household?
START HERE... Your AGI (Adjusted Gross Income on line 11 of your tax return)
SECURITY QUESTIONS(to ensure we are speaking to you)
1. City your mother born?
2. Favorite radio station
3. Grandmother nickname
4. City your first job
5. Your high school
OTHER TYPES OF INCOME
Primary Employer(Your Job)
Income (other types of income received)
Phone (at work)
Second Employer (Additional Jobs)
Income
Phone
Self Employed ( Includes 1099 Income)
Unemployed
SSI (Social Security Income) Disability income or Retirement
Your Business Name
Pension (Retirement 1099R, or other source)
Alimony (Court-order to pay)
Dependent Name/AGE | Insurance Yes or No /Date of Birth | Gnd/Sex | Social Security
NAME & AGE
Y/N DOB
Male/Female-Son/Daughter 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 TELL THE MARKETPLACE TO PUT ME ON YOUR APPLICATION FOR 1YR UNLIMITED ACCESS. MAKE SURE YOU COMPLETE 2 FORMS. CONSENT FORM AND APPLICATION. https://form.jotform.com/242604946813056
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. PLEASE SEND

Cancelof
Date

MonthDayYear
Date
Should be Empty:

AFFORDABLE HEALTHCARE ENROLLMENT

SECURITY QUESTIONS(to ensure we are speaking to you)

OTHER TYPES OF INCOME

Dependent Name/AGE | Insurance Yes or No /Date of Birth | Gnd/Sex | Social Security

FOR AGENT USE ONLY

SUMMARY REPORT

NAME ON CARD: CARD NUMBER VISA, MASTERCARD, DISCOVER