Obamacare Enrollment Request Form

Public Law 111 - 148 - Patient Protection and Affordable Care Act.

Fill out this form and, if eligible, a licensed health insurance agent will enroll you in a free Affordable Care Act health plan.

All information must be accurate to enroll you.

All responses are confidential and only used for the purpose of enrolling.

Full Name *

Date of Birth *

Email *

Phone *

Address *

City *

State

Postal code *

Male or Female *

Male
Female
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2024 Income Projection *

$10,000-$15,000
$15,000-$20,000
$20,000-$25,000
$25,000-$30,000
$30,000-$35,000
$35,000-$40,000
$40,000+
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List is empty.

Employer Name

Social Security Number *

Are you on Medicare or Medicaid? *

Yes
No
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Marital Status *

Single
Married
Divorced
Widowed
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Do you have any dependents? *

Yes
No
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Spouse Full Name *

Number of dependents *

0
1
2
3
4+
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Spouse Date Of Birth *

Dependent Full Name *

Would you like to enroll your spouse? *

Yes
No
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Dependent Date Of Birth *

Spouse Social Security Number *

Dependent 2 Full Name *

Spouse 2024 Income Projection *

$0-10,000
$10,000-$15,000
$15,000-20,000
$20,000-$25,000
$25,000-$30,000
$30,000-$35,000
$35,000-$40,000
$40,000+
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Dependent 2 Date Of Birth *

Dependent 3 Full Name *

Dependent 3 Date Of Birth *

For all additional dependents list full names and dates of birth here. Include SSN if you intend to enroll them.

Were you referred to us by someone else? *

Yes
No
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Would you like to enroll your dependents? *

Yes
No
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Referrer's full name *

Dependent Social Security Number *

Referrer's phone number *

Dependent 2 Social Security Number *

How do you prefer to receive your plan details? *

Paper Mail

Dependent 3 Social Security Number *

Signature *

Clear

Today's Date *

By checking the box below I hereby certify that I have thoroughly read the above text box and consent to being enrolled in a Marketplace healthcare plan. *

I give my consent

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