New Individual Enrollment Form

Agent Name:*
Person who referred youblanks Not required
Who are we quoting for Health Insurance (check all that apply)*

SelfSpouseDependents
Zip Code*
Required for Quoting
County*
Primary Contact *

First Last
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Date
Projected Annual Income 2026 (Entire Household)*
Tips and Overtime income (Max $25,000 tips, $12,500 OT//$25,000 OT for married )*
Since tips and overtime is non taxable 2026. This income will be subtracted from total income.
Email Address*
example@example.com
Phone Number*
Format: (000) 000-0000.
Tax Filing Status?*

SingleMarriedSingle w/dependentsMarried w/dependents
How many dependents are filing on your taxes at the end of the 2026*
Include anyone you take care of.
Spouse

First NameLast Name
Spouse Gender

MaleFemale
Spouse DOB

MonthDayYear
Date
Please provide information for any children/dependents that need to be included in your quote.
Name Date of Birth Sex M/F
NameDate of Birth Sex M/F
NameAge Sex M/F
NameAge Sex M/F
NameAge Sex M/F
NameAge
NameAge
Were any of these people found not eligible for Healthy Connections (Medicaid) or Healthy Connections (CHIP) in the past 90 days? (DOES NOT qualify for Medicaid or Chip)*

YesNoN/A
Does anyone use Tobacco products (more than 5 times in a week)*

NoYes
Recent Changes: Select any of the life changes that apply to any of the applicants. In some cases this must have taken place within the last 60 days*

Lost qualifying health coverageGot marriedChanged primary place livingReleased from jail or detentionAdopted/foster careNone
Place of Employment *
Citizenship*

United States citizenGreen cardNative American (Federally recognized)Other
List of Prescriptions:
We will use this data to filter your plan choices.
List of Doctors :
We will use this data to double check networks with carriers.
Employer Sponsored Coverage. Are any of these people currently offered health coverage through their job?*

SelfSpouseNONE
Do any of these people have an active COBRA plan or offer of coverage?*

SelfSpouseNONE
At 843 Benefits and Health Marketplace, we value your privacy but also want to provide you with the best possible guidance and education as you search for a health insurance solution. Please take a moment to review your selections as our advice is only as accurate as the information you provide.

By clicking the submit button below, you are authorizing us to contact you for the purpose of providing health insurance quotes for you and your family. We promise that your information is not shared or sold to anyone outside of our agency, and you will not be contacted by any other agent or marketing firm as a result of submitting this data.

P.S. You are also welcome to go ahead and schedule a free review or enrollment meeting using our online calendar system HERE.
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