Wright-Care Benefits PLLC

Benefit Consultant

Clients Full Name

First NameLast Name

Clients Date of Birth

MonthDayYear

Clients Full Social Security Number

Clients Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Clients ID: GOV ID, DL, Military ID, School ID, Birth Cert, SS card, Passport, Foreign ID, Voters ID or Work ID

Household size

Rows	Yes	No
Member
Member & Spouse
Children
More than one child

Notes/ Please enter Spouse and Children Names, Date of birth, and Social Security number in the box below. If not applicable please put N/A in box's (only if child is NOT on any state program such as: Medicaid, MediCal, or Chips

Clients Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

E-mail (Office Use Only)

example@example.com

Monthly Income

Name of profession/ Job/ Career/ or business/ if independent contractor please put "independent contractor "

Name of Doctor or Clinic

Please pick one Major Medical Insurance Choice

Life Insurance

I give my permission to Wright-Care Benefits to serve as myhealth insurance agent for myself and my entire household if applicable, forpurposes of enrollment in a Qualified Health Plan offered on the FederallyFacilitated Marketplace. By consenting to this agreement, I authorize theabove-mentioned agent to view and use the confidential information provided byme in writing, electronically, or by telephone only for the purposes of one ormore of the following1. Searching for an existing Marketplace application.2. Completing an application for eligibility and enrollmentin a Marketplace Qualified Health Plan or other government insuranceaffordability programs, such as Medicaid and CHIP or advance tax credits tohelp pay for Marketplace premiums.3. Providing ongoing account maintenance and enrollmentassistance, as necessary. 4. Responding to inquiries from the Marketplace regarding myMarketplace application.5. If you already have a Marketplace plan, you givepermission to switch you to a better plan if one is available, if you arealready on the best plan possible you are requesting Junnell Wright ( Wright-CareBenefits) to take over as your agent of record from this point forward unlessnotified of a change.6. I agree that if I am making less than 100% of the federalpoverty line that I am looking for work making at least minimum wage. I understand that the agent will not use or share mypersonal identifiable information (PII) for any purposes other than thoselisted above. The Agent will ensure my PII is kept private and safe whencollecting, starting, and using my PII for stated purposes above. I confirmthat the information I provided for entry on my Marketplace eligibility andenrollment application will be true to the best of my knowledge. I understandthat I do not have to share additional personal information about myself or myhealth with my Agent beyond what is required on the application for eligibilityand enrollment purposes. I understand that my consent remains in effect until Irevoke it, and I may revoke or notify my consent at any time by sending anemail, text, or phone call to Wright-Care Benefits at +1-877-622-5136 Name of Primary Writing Agent: Junnell WrightAgent National Producer Number: 14761754Phone Number: +1-1877-622-5136Email Address :Junnellwright@wrightcarebenefits.com

No Cost Health Insurance: