Application for Health Coverage & Help Paying Costs

1

2

If you need assistance filling out this application please call (214) 675-0999 Please contact your Agent with any questions or updates as they are needed.

3

Health Insurance App for Quoting & Enrollment - In compliance with information needed and obtained TEXINS.CODE Title2SubACh30

4

STEP 1: Tell us about yourself

5

BCBSTX Plan Selection

$0 MONTHLY/$50 DED $900 OOP / $5 DR COPAY (2 PER YEAR) --------Rx $0 GENERIC / 30% BRAND

$26 MONTHLY/$125 DED $750 OOP / $5 DR COPAY (UNLIMITED)----------Rx $5 GENERIC / 30% BRAND

6

(We need one adult in the family to be the contact person for your application)

7

1. Name* This field is required.

First name

Middle name

Last name

Suffix

8

2. Home address (Leave blank (N/A) if you dont have one.)* This field is required.

9

3. Apartment or suite number

10

4 City* This field is required.

11

5. State* This field is required.

12

6. Zip code* This field is required.

13

7. County, parish, or township* This field is required.

14

8. Mailing addresss (if different from home address)

15

9. Apartment or suite number

16

10. City

17

11. State

18

12. Zip code

19

13. County, parish, or township

20

14. Daytime phone number* This field is required.

21

15. Evening phone number* This field is required.

22

16. Email address:* This field is required.

example@example.com

23

17. Are you married?* This field is required.

Y

N

24

18. Date of birth (mm/dd/yyyy)* This field is required.

Date

25

19. Sex* This field is required.

Male

Female

26

20. Social Security Number (SSN)

YOU MAY LEAVE BLANK AND OPT TO HAVE AN AGENT CALL OR EMAIL YOU TO GET THIS INFO IF YOU DON'T ENTER ABOVE

27

21. Applying for coverage?* This field is required.

Y

N

28

22. Do you plan to file a federal tax return NEXT YEAR?* This field is required.You can still apply for coverage even if you don't file a federal tax return.

Y

N

29

23. Will you file with a spouse?* This field is required.

Y

N

30

Spouse name

31

Date of birth

Date

32

Social security

YOU MAY LEAVE BLANK AND OPT TO HAVE AN AGENT CALL OR EMAIL YOU TO GET THIS INFO IF YOU DON'T ENTER ABOVE

33

Male or Female

M

F

34

CHILDREN UNDER THE AGE OF 18-FREE DENTAL

35

24. Will you file with a dependent/dependents?* This field is required.

Y

N

36

Dependents name

37

Date of birth

Date

38

Social security

YOU MAY LEAVE BLANK AND OPT TO HAVE AN AGENT CALL OR EMAIL YOU TO GET THIS INFO IF YOU DON'T ENTER ABOVE

39

Male or Female

M

F

40

Dependents name

41

Date of birth

Date

42

Social security

YOU MAY LEAVE BLANK AND OPT TO HAVE AN AGENT CALL OR EMAIL YOU TO GET THIS INFO IF YOU DON'T ENTER ABOVE

43

Male or Female

M

F

44

Dependents name

45

Date of birth

Date

46

Social security

YOU MAY LEAVE BLANK AND OPT TO HAVE AN AGENT CALL OR EMAIL YOU TO GET THIS INFO IF YOU DON'T ENTER ABOVE

47

Male or Female

M

F

48

Dependents name

49

Date of birth

Date

50

Social security

YOU MAY LEAVE BLANK AND OPT TO HAVE AN AGENT CALL OR EMAIL YOU TO GET THIS INFO IF YOU DON'T ENTER ABOVE

51

Male or Female

M

F

52

Current job: EX. - JOB / SCHOOL / CASH SUPPORT (PARENT OR WHO?)

53

25. Employer name* This field is required.

54

26. Employer phone number* This field is required.

55

27. Your total income (household)* This field is required.

56

28. Please state the person who referred you/how you heard about us?* This field is required.

57

Income for 2019: PERSON 1 should sign this application. If you're an authorized represenative, you may sign here as long as PERSON 1 signed Appendix C.

58

Signature

59

Date Signed (mm/dd/yyyy)

60

By signing this agreement you are stating that you are who you say you are and that the information given is true and correct to the best of your knowledge.

61

Please see the reverse of this document for agent authorization and to finalize your application for health insurance.

62

Additional notes: IF YOU NEED HELP WITH YOUR APPLICATION CALL (214)675-0999 Para obtener una copia de este formulario en Espanol, llame (972)613-4911

63

CONTACT YOUR AGENT (214) 675-0999 FOR ALL INQUIRES & UPDATES IF THE INFORMATION ABOVE CHANGES.

64

ARE YOU INTERESTED IN ADULT DENTAL PLANS OR A LIFE INSURANCE POLICY?

Y

N

65

Additional notes:

66

BLUE CROSS BLUE SHIELD / MOLINA HEALTHCARE / AMBETTER / UNITED HEALTHCARE / AETNA / CIGNA / HUMANA / HEALTHCARE.GOV / YOURTEXASBENEFITS.COM

67

2019 CLIA app ORO

TXSTINSLIC1239187 10/03

68

If you need assistance filling out this application please call (214) 675-0999 Please contact your Agent with any questions or updates as they are needed.

69

(If you have been incarcerated within past year)

70

NAME

71

stands before me on

72

DATE

Date

73

I certify by his/her identification and physical presence,

that he/she is NOT incarcerated and is a citizen of the community, in free world population. Please feel free to contact me with any concerns to this matter. Thank you,- Chance Luna, Broker

74

You may choose an authorized represenative

Assistance with completing this application

75

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an "authorized represenative." If you ever need to change or remove your authorized represenative, contact the marketplace. If you're a legally appointed rep please submit proof with this application.

76

APPLICANT AUTHORIZATION: THIS LETTER OF AGENT IS TO BE RECOGNIZED BY, BUT NOT LIMITED TO, ALL REPRESENATIVES AND STAFF OF THE MARKETPLACE, CMS, BLUE CROSS BLUE SHIELD OF TEXAS, MOLINA HEALTHCARE, TEXAS HEALTH AND HUMAN SERVICES, AND THE TEXAS DEPARTMENT OF INSURANCE.

77

Please recognize Chance Luna of CHANCE! Luna Insurance Agency NPN 7831899 as my agent of record with respect to all applications, policies, and all health insurance and marketplace related matters. Including but not limited to aspects of the policy plan and its active renewal. This letter grants authority by me, to CHANCE! Luna Insurance Agency for the next 365 days.

78

HEREBY SELECTING CHANCE LUNA AS AGENT UNTIL FURTHER NOTICE IN WRITING BY THE APPLICANT.

79

1. Name of authorized represenative (First name, Middle name, Last name)

80

2. Address

81

3. Apartment or suite

82

4. City

83

5. State

84

6. Zip code

85

7. Phone number

86

8. Organization name

87

9. Agents/Brokers only : NPN number

88

By siging this agreement I am giving the privilege to Chance Luna Ins Agency of my consent to open online accounts with healthcare.gov and other websites in order to enroll in health coverage . I also am aware that if request information in regards to account details I may contact CLIA to obtain. I understand that if my income changes or I have a lifestyle change I am to contact the Marketplace AND Chance Luna Ins Agency to update

my account AND if I ever choose to cancel my coverage that I must do so in writing and I must contact Chance Luna Ins Agency 214.675.0999 or 972.613.4911.

By signing, you allow this person to sign your application, get offical information about this application, and act for you on all future matters related to this application and other health insurance policy plan and account needs.

89

PRINT YOUR NAME

90

SIGNATURE

91

I understand this agreement can be written or verbal through telephonic communication and by choosing to enroll in health insurance through CLIA am bound by the formentioned and allow Chance Luna Insurance Agency the privilege of the information provided for use in accounts, enrollment, & ALL insurance matters.

92

IF ANY OF THE ABOVE INFORMATION CHANGES PLEASE CALL YOUR AGENT CHANCE LUNA (214) 675-0999

(972) 613-4911 office (972) 613-3671 fax (214) 675-0999 cell admin@lunainsurance.com email lunainsurance.com website

93

Any questions or concerns with any insurance related matters, please feel free to contact Luna Insurance Agency. Thank you for your prompt attention in this matter Chance Luna, Broker (972) 613-4911 552 West Interstate 30, Suite 317 Garland, Texas 75043 admin@lunainsurance.com www.lunainsurance.com

94

We change this Privacy Policy from time to time. We will not reduce your rights under this Privacy Policy without your explicit consent. We always indicate the date the last changes were published and we offer access to archived versions for your review. If changes are significant, we’ll provide a more prominent notice (including, for certain services, email notification of Privacy Policy changes).

Please visit www.LUNAINSURANCE.com for more info on our private policy AND Terms of Conditions.

95

2019 CLIA app ORO

TXSTINSLIC1239187 10/03