SIMPLE APPLICATION

SIMPLE WAYS TO MAKE YOUR APPLICATION

FASTER TO COMPLETE

WE MAKE IT SIMPLE.

Health Insurance As Low As $0 Monthly

Read Statement: YOU AGREE TO HAVE ZECO MIAMI AUTHORIZED REPRESENTATIVES TO ACCESS YOUR PERSONALLY INDENTIFIABLE INFORMATION TO CONDUCT AN ONLINE SEARCH FOR YOU AND/OR FAMILY TO ASSIT WITH MARKETPLACE APPLICATION, ENROLLMENT AND ONGOING ACCOUNT MAINTENANCE FOR A YEAR STARTING TODAY. THE INFORMATION/ DOCUMENTATIONS COLLECED WILL ONLY BE USED FOR THE PURPOSE OF GETTING HEALTHCARE COVERAGE THROUGH THE MARKETPLACE. ALL YOUR INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL. YOU CONFIRM THAT THE INFORMATION PROVIDED WILL BE TRUE TO THE BEST OF YOUR KNOWLEDGE. YOU ALSO AGREE THAT THE AGENT HELPING YOU HAS EXPLAINED THAT YOU HAVE A RESPONSIBILITY TO REPORT ANY HOUSEHOLD CHANGES THAT MAY AFFECT YOUR COVERAGE. TO REVOKE OR CANCEL CONSENT, YOU MUST ADVISE YOUR AGENT BY EMAIL OR PHONE.

YOUR AGENT: MAYKIE FORTUNE AT ZECO MIAMI INC.- 305-203-9835 EMAIL:MAYKIE@ZECOMIAMI.COM

Health Insurance Marketplace may ask to submit your documents; proof of income Immigration status
Referred By
Name*

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Gender*

FemaleMaleOther
SOCIAL SECURITY*
IF FOR ANY REASON YOU DONT HAVE A SS ENTER 000-00-0000 PLEASE PUT REASON IN THE NOTE BELOW
Address*

Street Address

APT #

CityState

Zip Code
Date of birth: *
Immigration/ Citizenship Status *
Phone Number *
Please enter a valid phone number.
By entering your phone number, you agree to allow Zeco Miami and its associates to contact you regarding policy updates and agency/ insurance-related matters. Should you wish to opt out of receiving these communications after submitting this form, please contact us at Maykie@ZecoMiami.com . Your information will be handled in accordance with our privacy policy.

ZECO MIAMI PRIVACY POLICY
Valid Email:*
How frequent is your income:*

WEEKLYBI-WEEKLYMONTHLYANNUALOther
CURRENT INCOME*
INCOME TYPE

EMPLOYEDSELF EMPLOYEDOther Income Type
Job Name/ Occupation:
Do you file a Joint Tax?*
Spouse Name*

First NameMiddle NameLast Name
Spouse Gender*

FemaleMaleOther
Spouse Date of birth: *
Spouse SOCIAL SECURITY*
IF FOR ANY REASON YOU DONT HAVE A SS ENTER 000-00-0000 PLEASE PUT REASON IN THE NOTE BELOW
Does your spouse have income?*

YesNo
SPOUSE CURRENT INCOME*
How frequent is your Spouses income:*

WEEKLYBI-WEEKLYMONTHLYANNUALOther
WHAT IS YOUR SPOUSE INCOME TYPE

EMPLOYEDSELF EMPLOYEDOther Income Type
Spouse Immigration/ Citizenship Status *
Do You Have Any Tax Dependents ? (Children, Parents etc)*

YESNO
list all TAX DEPENDENTS *
Do you need health insurance for yourself?
Who else do you need coverage for?*

My SpouseMy kids or dependentsNONE
If there is any note, Please add it in the box

NOTE: If you plan on filing income tax with your kids/dependents (we need the Full name, Gender, Date of birth, and immigration/citizenship status)

Please Include your spouse and tax dependents even if they don't need health Insurance coverage.

If you plan to claim someone as a tax dependent for the year you want coverage, Please include them on your application.

If you won't claim them as a tax dependent, don't include them.
If there is any note, Please add it in the box
I certify that the information above is true and accurate to the best of my knowledge
My Health Insurance Budget is:*

$0 A MONTHUNDER $10 A MONTHUNDER $50 A MONTHI DON'T MIND PAYING OVER $100 FOR A PLAN
DO YOU HAVE A CARRIER PREFRENCE?

NO, HELP ME CHOOSEAMBETTER SUNSHINE HEALTHAETNA CVSOSCARMOLINACIGNAFLORIDA BLUEUNITED HEALTHCAREAVMEDAMERI HEALTH
DO YOU ALREADY HAVE A DOCTOR?*

YESNO
PLEASE LIST ALL PROVIDERS NAME INCLUDING PRIMARY CARE AND SPECIALIST:*
ARE TAKING PRESCRIBED MEDICATION?*

YESNO
PLEASE LIST ALL PRESCRIPTIONS YOU NEED COVERED: *
File Upload

upload income documents immigration and or citizenship documents here
Cancelof
SIGN HERE*

Clear
Should be Empty:

ZECO MIAMI PRIVACY POLICY