(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

12

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

38

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

47

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.

53

I, {name}, have reviewed the Marketplace eligibility application information and confirmed its accuracy prior to the application being submitted. The agentexplained the attestations at the end of the eligibility application to me prior to the application being submitted and I was given an opportunity to ask questions about them.

I understand that the agency will not use or share my personally identifiable information (PII) for any purposes other than those to which I consented. The agency will ensure that my PII is kept private and safe when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the purposes I consented to. I understand that I do not have to share additional PII or protected health information (PHI) with my agency beyond what is required on the Marketplace application for eligibility and enrollment purposes.

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 Below
Date: {date}

54

I, {name}, have reviewed the Marketplace eligibility application information and confirmed its accuracy prior to the application being submitted. The agentexplained the attestations at the end of the eligibility application to me prior to the application being submitted and I was given an opportunity to ask questions about them.

I understand that the agency will not use or share my personally identifiable information (PII) for any purposes other than those to which I consented. The agency will ensure that my PII is kept private and safe when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the purposes I consented to. I understand that I do not have to share additional PII or protected health information (PHI) with my agency beyond what is required on the Marketplace application for eligibility and enrollment purposes.

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 Below
Date: {date}

55

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

First Name

Last Name

56

Date

57

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. By submitting this request for health insurance you are agreeing to be contacted via phone, text and/or email about your coverage. To revoke consent send a written request at any time to info@americafirstinsurancegroup.com or reply Stop to stop or Help for help.

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