Health Insurance Client Intake Form (ACA 2026 Enrollment)

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
Full Name of the Primary Applicant

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Income & Employment Details
Will you file taxes for this year?

YesNo
How many people in your household earn income?
Earner 1 Full Name

First NameLast Name
Earner 1 Employment Status
Company name
Earner 1 Monthly Income (Gross)
Earner 2 Full Name

First NameLast Name
Earner 2 Employment Status
Company name
Earner 2 Monthly Income (Gross)
Earner 3 Full Name

First NameLast Name
Earner 3 Employment Status
Company name
Earner 3 Monthly Income (Gross)
Estimated total household income

Would you like to schedule a call with your agent to review details before the Open Enrollment Period begins?

YesNot SureNo, submit with the data I provided
Appointment

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?

YesNo
Please provide the names and phone numbers of a few people who may be interested in health insurance. No obligation to buy — just ask if they’d like our help reviewing their options. As a thank-you for sharing our services with friends and family, you’ll receive a FREE 1-year Identity & Cash Theft Protection policy.
Do you want to add something else?

YesNo
Please provide additional information

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.
File Upload

Cancelof

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
Signature

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Health Insurance Client Intake Form (ACA 2026 Enrollment)

Contact Information

Household Members Composition

Income & Employment Details

Life Change Circumstances

Current Insurance Info

Additional services

Uploads

Consent & Signature