(WEB) Qualified Health Coverage

1

Are you looking for Individual or Family Coverage?* This field is required.

Individual

Family

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Zip Code* This field is required.

4

What is your estimated household income for the year* This field is required.

5

How many household members do you claim on your taxes?* This field is required.

6

Ages of everyone that needs coverage* This field is required.

7

9

Name* This field is required.

First Name

Last Name

10

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

11

Email* This field is required.

example@example.com

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Date of Birth* This field is required.

Date

13

Occupation or Line of Work* This field is required.

14

Are you married?* This field is required.

YESNO

15

Spouse Name

First Name

Last Name

16

Spouse Date of Birth

Date

17

Do you have any dependents?

YESNO

18

First Dependent Name

First Name

Last Name

19

First Dependent Date of Birth

Date

20

Do You have another dependent?

YESNO

21

Second Dependent Name

First Name

Last Name

22

Second Dependent Date of Birth

Date

23

Do You have another dependent?

YESNO

24

Third Dependent Name

First Name

Last Name

25

Third Dependent Date of Birth

Date

26

Do You have another dependent?

YESNO

27

Fourth Dependent Name

First Name

Last Name

28

Fourth Dependent Date of Birth

Date

29

Do You have another dependent?

YESNO

30

Fifth Dependent Name

First Name

Last Name

31

Fifth Dependent Date of Birth

Date

32

Do You have another dependent?

YESNO

33

Sixth Dependent Name

First Name

Last Name

34

Sixth Dependent Date of Birth

Date

35

Do You have another dependent?

YESNO

36

Seventh Dependent Name

First Name

Last Name

37

Seventh Dependent Date of Birth

Date

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Do You have another dependent?

YESNO

39

Eighth Dependent Name

First Name

Last Name

40

Eighth Dependent Date of Birth

Date

41

Do You have another dependent?

YESNO

42

Ninth Dependent Name

First Name

Last Name

43

Ninth Dependent Date of Birth

Date

44

Do You have another dependent?

YESNO

45

Tenth Dependent Name

First Name

Last Name

46

Tenth Dependent Date of Birth

Date

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The Centers for Medicare & Medicaid Services (CMS) have now made it mandatory to provide the consumers SSN on the Marketplace application if the consumer has a SSN. If you do not enter a SSN when the consumer has one, they may lose coverage or financial assistance. If you do not wish to provide your SSN for your application, you will be required to submit proof of Citizenship and Income Verification within a period of time to continue coverage. Please provide your SSN below.* This field is required.

This is a HIPPA secure document.

48

IF any member of your household is also applying for coverage, please provide their Name and SSN here. If you are not married, have no dependents or are the only one needing coverage type NA* This field is required.

49

Are you currently insured?

YESNO

50

Who is your current carrier?

51

Why do you want to change?

52

What do you want out of your coverage? Looking for specific doctors in network...list the doctor's names. Looking for specific medications covered...list the medications and dosages. Looking for specific benefits...list them. Please be as detailed as possible.

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SignatureThank you for confirming your authorization. If you have any questions, please do not hesitate to call us at 877.999.5469.. By completing this form you authorize us to contact you by phone, text and/or email with details of your coverage or other updates pertinent to you or your family.

Powered by Jotform SignClear

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Date

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I, {name}, give my permission to America First Insurance Group's agents 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 the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

Searching for an existing Marketplace application;
Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums;
Providing ongoing account maintenance and enrollment assistance, as necessary; or
Responding to inquiries from the Marketplace regarding my Marketplace 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 confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. 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 emailing info@americafirstinsurancegroup.com.

By completing this form you are also consenting to be contacted by our agency via call or text about your health insurance request. To opt out please email info@americafirstinsurancegroup.com and/or by replying STOP to stop.

Name of Primary Writing Agent: Heather Agnew/Adalberto Rodriguez
Agent National Producer Number: 17323715/17359948
Phone Number: (877) 999-5469
Email Address: info@americafirstinsurancegroup.com

Name of Agency (if applicable): America First Insurance Group
Agency National Producer Number: 19491127
Owner of Agency: Heather Agnew/Adalberto Rodriguez
Phone Number: (877) 999-5469
Email Address: info@americafirstinsurancegroup.com

Name of Primary Household Contact
and/or Authorized Representative: {name}
Email Address: {email}
Signature: See Signature Above
Date: {date}

56

Renewal of Coverage* This field is required.To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.

YESNO

57

Tax attestation* This field is required.I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, Children's Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit.

YESNO

58

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents:

I must file a federal income tax return for the 2025 tax year.
If I’m married at the end of 2025, I must file a joint income tax return with my spouse.

I also expect that:

No one else will be able to claim me as a dependent on their 2025 federal income tax return.
I’ll claim a personal exemption deduction on my 2025 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.

If any of the above changes:

I understand that it may impact my ability to get the premium tax credit.
I also understand that when I file my 2025 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

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Type a question* This field is required.

YESNO

60

Sign and SubmitI know that I must tell the program I’ll be enrolled in within 30 days if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). I know a change in my information could affect eligibility for member(s) of my household.

I agree

I disagree

61

If anyone on your application is enrolled in Marketplace coverage and is also found to have Medicare coverage, the Marketplace will automatically end their Marketplace plan coverage. They will get a notice before Marketplace terminates their coverage in case they need to keep it or make changes. During all the months of overlapping coverage, they're responsible for paying the full cost for the Marketplace plan premium and covered services.* This field is required.

I agree to allow the Marketplace to end the Marketplace coverage for anyone on my application who's enrolled in both Marketplace and Medicare coverage.

I don't give the Marketplace permission to end Marketplace coverage for anyone on my application who's enrolled in both Marketplace and Medicare coverage. I understand that they will have a Marketplace health plan without financial help and pay the full cost for their share of the Marketplace plan premium and covered services, if eligible.

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I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.

I agree

I disagree

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Type your full name below to sign electronically* This field is required.

First Name

Last Name