AFFORDABLE AMERICAN

HEALTH CARE

AFFORDABLE AMERICAN

HEALTH CARE

Get NEW Subsidized MarketPlace

ObamaCare Now!

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications.

One of our Marketplace Specialists will Process your application to get you the best coverage possible

Do you have insurance through your employer, Medicare, Medicaid or VA? *

Yes

Are you currently employed? *

Yes

Employer Name *

Male or Female *

Must Use Legal Name Shown On Your Identification

First Name *

Last Name *

Address *

City *

State *

Postal code *

Phone *

Email *

What is your social security #? *

Date Of Birth (mm/dd/yyyy)

Total Number Of Household Members (total number on tax filing) *

Are you including a spouse/dependent to this coverage? *

Yes

Please Be Accurate - Your Income Will Be Verified By Healthcare.gov

What is Your Expected Household Income Per Month *

Marketplace Consent *

By checking this box, I hereby provide consent to my agent (Romeo Douangmala) to enroll me and/or my family in a health insurance plan through the ACA Marketplace at no cost to you. If I already have a plan, I request that Romeo Douangmala become my agent of record and switch me to a better plan if one is available.

* *

If your income is $0 (or less than the Federal Poverty Limit), you attest that your estimated income for 2023 will be at least the Federal Poverty Limit for your state and household requirements. If your income will be less than (or greater than) those limits, you agree to notify us or the marketplace of any changes or updates as soon as possible. Failure to notify us of any changes may result in your eligibility being affected. Job Seeking: I Agree to notify my agent or healthcare.gov if my estimated income for 2023 changes.

* * *

In some cases, it may be necessary to verify your income. If income verification is required in order to complete your enrollment, do you authorize your agent (Romeo Douangmala) to submit an income attestation letter on your behalf with the information that you have provided?

* * * *

By checking this box I provide my express consent to my agent (Romeo Douangmala) a limited power of attorney to enroll me in a health insurance plan and to automatically enroll me in a plan at renewal.

Acknowledgement

I have read and agree to the terms above and I attest that the personal information I have provided is true and correct

Clear

Dependent #1

Full Legal Name
Relationship to Applicant
Birth Date
Social Security #
Do they need coverage (Y/N)

Need to add a 2nd dependent? *

Yes

Dependent #2

Full Legal Name
Relationship to Applicant
Birth Date
Social Security #

Need to add more dependents? *

Yes

List ALL other dependents that need coverage (Full legal name, Relationship, DOB, SSN)

Get NEW Subsidized MarketPlace

ObamaCare Now!

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications. One of our Marketplace Specialists will Process your application to get you the best coverage possible

AFFORDABLE AMERICAN

HEALTH CARE

AFFORDABLE AMERICAN

HEALTH CARE

Get NEW Subsidized MarketPlace

ObamaCare Now!

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications.

Get NEW Subsidized MarketPlace

ObamaCare Now!

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications. One of our Marketplace Specialists will Process your application to get you the best coverage possible

All Rights Reserved - 2022

All Rights Reserved - 2022