Marketplace Enrollment Worksheet 2025

Marketplace Enrollment Worksheet 2025

Agent Jatavious Wilson
What type of insurance do you want? (Check all that apply)

MedicalDentalVisionType option 4
Name*

First NameMiddle InitialLast Name
D.O.B.*

MonthDayYear
Date
SSN:*
Social Security
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
US Citizen*

YesNo
Green Card Uscic #
Smoker

YesNo
American Indian, Alaskan Native or Hispanic?

YesNo
Ethnicity

WhiteBlackOther
Marital Status*

SingleMarried
Pregnant?

YesNo
Employer Name (If self employed put self, if unemployed put source of income)*
Name of Employer
Employer #*
Employer Phone # (If self employed put your number. )
Income (Please fill out at least 1, weekly, bi-weekly, monthly or yearly)(If you do not have an income, you will not be eligible for the subsidies, will have to pay a full price)(Provide Estimated Adjusted Gross Income, which is your gross income minus any deductions you're eligible to claim)
Weekly Income Bi-Weekly Income Monthly Income Yearly Income
Spouse Information First Name Last Name Middle Initial DOB WifeHusbandDomestic Partner Email SSN Area Code Phone Number Spouse Employer Employer Area Code Employer Phone Number Income (Please fill out at least 1, weekly, bi-weekly, monthly or yearly)
Weekly Income Bi-Weekly Income Monthly Income Yearly Income
Dependent #1
First Name Middle Initial Last Name DOB Male Female SSN
Dependent #2
First Name Last Name Type a label DOB Male Female SSN
Dependent #3
First Name Last Name Type a label DOB Male Female SSN
Dependent #4
First Name Last Name Type a label DOB Male Female SSN
Dependent #5
First Name Last Name Type a label DOB Male Female SSN
Which SEP Used: (Fill out only if applies to you)
Denied Medicaid Date
If you have a referral code, enter here.
Customer Acknowledges receipt of HIPPA Privacy information at time of enrollment. Customer agrees to allow Jatavious Wilson Agent access to their Healthcare.gov account to make updates/uploads as necessary and to be able to review and advise Customer, year to year (indefinitely until customer rescinds), to ensure that Customer has made a sound decision in their Marketplace Healthcare plan selection for the year. This permission is granted until rescinded by the customer through written notification.*

Yes
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty: