Health Insurance Client Intake Form (ACA 2026 Enrollment)
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  • Health Insurance Client Intake Form (ACA 2026 Enrollment)

    Estimated completion time: approximately 8 minutes.

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  • Please complete this form to help us find most suitable and affordable Marketplace (ACA) plan for you and your family for the 2026 plan year.
    After submission, we will contact you to review your information and confirm your eligibility.

    Tips:

    Fill out all fields as accurately as possible.

    If you’re unsure about any question, leave a note in the “Comments” section at the end.

    You may upload your supporting documents now or send them later. 

    All information is protected, HIPAA-compliant and used solely to prepare Marketplace (ACA) application. Please enter the data according to the request.

    Contact support: email support@insur.live or call (305)775-3215

  • Contact Information

  • Format: (000) 000-0000.

  • Household Members Composition

  • Date of Birth of the Applicant 1
     - -
  • Need coverage?
  • Date of Birth of the Applicant 2
     - -
  • Need coverage?
  • Date of Birth of the Applicant 3
     - -
  • Need coverage?
  • Date of Birth of the Applicant 4
     - -
  • Need coverage?
  • Date of Birth of the Applicant 5
     - -
  • Need coverage?
  • Date of Birth of the Applicant 6
     - -
  • Need coverage?

  • Income & Employment Details

  • Will you file taxes for this year?

  • Special Enrollment Period (SEP) Eligibility

    A Special Enrollment Period allows you to enroll in or change your health insurance outside of Open Enrollment if you experienced a Qualifying Life Event (QLE) within the last 60 days (or expect one in the next 60 days).
  • Do you qualify for a Special Enrollment Period (SEP)?
  • Qualifying Life Events (Select all that apply)

  • Current Insurance Info

  • Do you currently have insurance?
  • Do you get insurance from an employer (self or spouse)?
  • Had you Medicaid recently?
  • End Date of the Medicaid
     - -
  • Do you have any preferences for doctors who should accept your insurance plan?
  • Do you require any specific medications or services that should be covered by your insurance plan?

  • Additional services

  • Would you be interested in exploring separate products that include the following options?
  • Would you like to join our promotional thank-you program and get a FREE $1M Identity & Cash Theft Protection policy while helping your friends and family find the best health insurance?
  • Do you want to add something else?

  • Uploads

  • Please upload the necessary documents as requested. This will help us complete your enrollment accurately.

    Required documents may include:

     

    1. Proof of Immigration status (Permanent Resident Card (Green Card)
    Employment Authorization Document (EAD)
    Arrival/Departure Record (Form I-94)) for each applicant

    2. Any other documents you wish to add 

     

    All files are encrypted and stored securely. You can also send documents later to your agent by email if needed.

  • Browse Files
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  • Consent & Signature

  • I {fullName} give my permission to Gennadii Zolotov ("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 or State Based Exchange (SBE). By consenting to this agreement, I 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 or SBE application
    • Completing an application for eligibility and enrollment in a Marketplace or SBE Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace or SBE premiums
    • Providing ongoing account maintenance and enrollment assistance, as necessary
    • Responding to inquiries from the Marketplace or SBE regarding my application

    I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

    I understand that I 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. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my Agent.

    Agent name: Gennadii Zolotov

    Agent NPN: 21076241

    Agent phone: (305) 775-3215

     

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