Discover Your Eligibility For Affordable Healthcare
Find the peace of mind that comes with the perfect health plan! Our team is dedicated to finding you an affordable solution that fits your family's needs. Simply fill in your details below, and let us take care of evaluating your insurance requirements and customizing options just for you. Our goal is to get you the most benefits for the least cost possible!
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Applicant Social Security Number *
*
example@example.com
Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Other
Employment Type
*
Please Select
Unemployed
1099
W2
Self-Employed
What is your expected income after tax deductions and write offers between January and December of THIS year?
Employer or Business Name
Enter the employer or business name
Employer or Business Phone Number
Enter the employer or business name
Does Your Employer Offer Insurance? *
*
Yes
No
Annual Salary *
*
Do You Have Other Insurance? *
*
No Other Insurance
Other Insurance
Group Insurance
Medicaid
Medicare
Are You Married? *
*
Yes
No
How Many People live in the home that file taxes with you? - Spouse Included *
*
Please Select
0
1
2
3
4
5
6
7
8
How many children will be on the application? *
*
Please Select
0
1
2
3
4
5
6
7
8
Do any applicants need glasses/contacts? *
*
Yes
No
List Any Current Doctors and Medications You Need Covered: *
*
Agent Full Name *
*
Anthony
Benedict
Agent Full Name
Anthony Benedict / Blake Moree
Agent Phone Number *
*
5616290590
My job is to secure you the most benefits for the most affordable cost, that said, what is a reasonable budget to cover everyone that needs health insurance? *
*
Please Select
~below 40/mo
~40/mo
~80/mo
~150/mo
~225/mo
~300/mo
~500/mo
Consent Agreement
*
I hereby give my permission to Monarch Insurance Agency Solutions (NPN 21498121, 21495656), as mentioned in this agreement, 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. By consenting to this agreement, I authorize and its affiliates to: View and use the confidential information provided by me in writing, electronically, or by telephone for the purposes of: Searching for an existing Marketplace application. I consent to receiving automated phone calls, SMS, and email messages using templated messages or Artificial Intelligence (AI) to help collect information or communicate with me. Standard message and data rates may apply, messaging frequency varies, and consent is not a condition of purchase. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs. Providing ongoing account maintenance and enrollment assistance, as necessary. Responding to inquiries from the Marketplace regarding my application. Act as my Agent of Record concerning all matters related to my health insurance. This designation allows and its affiliates to represent and assist me in all interactions with the health insurance provider. Ensure that my Personally Identifiable Information (PII) is kept private and safe when collecting, storing, and using it for the above purposes. and its affiliates commit to not sharing my PII for any purposes other than those explicitly stated in this agreement. I further attest to one or more of the following conditions being true: My income meets the minimum required to qualify for subsidized healthcare under the Federally Facilitated Marketplace. I, or someone in my household, have experienced a qualifying life change in the past 60 days that qualifies for a Special Enrollment Period. I, or someone in my household, either lost qualifying health coverage in the past 60 days or expect to lose coverage in the next 60 days. Scope of Appointment: I appoint , Monarch Insurance Agency Solutions (NPN 21498121, 21495656) as my representative for up to 10 years for the above mentioned purposes. I grant the parties mentioned to contact me via phone, email, and/or text. Revocation: I understand that my consent remains in effect until I revoke it. I may revoke or modify my consent at any time by contacting Monarch Insurance Agency Solutions (NPN 21498121,21495656) and its affiliates at support@monarchagencysolutions.com, 561-709-3617: . Reply HALT to opt-out and unsubscribe from SMS messages. I consent to allow my new Agent of Record (AOR) to send letters, emails, and phone calls on my behalf for the purpose of contacting and revoking any previous AOR from accessing my private information or attempting to change AOR or plans without my express verbal and signed consent.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
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