Health Insurance Application

Affordable Health Insurance Validation Form

First Name *

Last Name *

Gender

Male

Female

Email *

Phone *

Projected Annual Income *

$

I give my permission to Genesis Martillo to serve as my health insurance agent for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following

1. Searching for an existing Marketplace application.

2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums.

3. Providing ongoing account maintenance and enrollment assistance, as necessary.

4. Responding to inquiries from the Marketplace regarding my Marketplace application.

5. If you already have a Marketplace plan, you give permission to switch you to a better plan if one is available, if you are already on the best plan possible you are requesting to take over as your agent of record from this point forward unless notified of a change.

6. I agree that if I am making less than 100% of the federal poverty line that I am looking for work making at least minimum wage.

I understand that the agent will not use or share my personal identifiable information (PII) for any purposes other than those listed above. The Agent will ensure my PII is kept private and safe when collecting, starting, and using my PII for stated purposes above. I confirm that the information I provided for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or notify my consent at any time by sending an email, text, or phone call to at:

Name of Primary Writing Agent: Genesis Martillo

Agent National Producer Number:17240516

Phone Number: (866) 301-6044

Email Address: gmartillo@coverancegroup.com

Authorization Signature *

Clear

Primary Applicant's Social Security Number *

Date of birth *

Tobacco

I was found not eligible for Medicaid or CHIP in the last 90 days. *

Yes

No

Do you have a doctor you would like to keep? *

Yes

No

Marital Status *

Address *

City *

State *

Postal code *

Spouse Name *

Spouse Social Security *

Spouse DOB *

Spouse Gender *

Male

Female

Do you want us to enroll your spouse? *

Yes

No

Do you have dependents *

Yes

No

I don't understand

Dependent #1 *

First Name
Last Name
DOB
Social Security Number
Relationship

Do you have a 2nd dependent?

Yes

No

Dependent #2

First Name
Last Name
DOB
Social Security Number
Relationship

Do you have a 3rd Dependent?

Yes

No

Dependent #3

First Name
Last Name
DOB
Social Security Number
Relationship

Do you have a 4th Dependent?

Yes

No

Additional Dependents

Dependent #4

First Name
Last Name
DOB
Social Security Number
Relationship

Do you have a 5th Dependent?

Yes

No

Dependent #5

First Name
Last Name
DOB
Social Security
Relationship

Do you have a 6th Dependent?

Yes

No

Dependent #6

First Name
Last Name
DOB
Social Security
Relationship

Do you have a 7th Dependent?

Yes

No

Dependent #7

First Name
Last Name
DOB
Social Security
Relationship

Do you have a 8th Dependent?

Yes

No

Dependent #8

First Name
Last Name
DOB
Social Security
Relationship

Employment *

I agree that I have read this attestation and I give my permission to to serve as my broker for myself and my household, for the purpose of enrollment in a qualified Health Plan offered by the Federally Facilitated Marketplace. I consent to allow the above mentioned agent to view and use my confidential information for the following purposes:

1. Search for an existing Marketplace Plan;

2. Complete an application for eligibility and enrollment in a Marketplace Plan;

3. Provide ongoing maintenance and enrollment assistance; or

4. Respond to inquiries from the Marketplace regarding my application.

I confirm what I have shared is accurate and true for entry on my Marketplace Health Insurance Application, that I have read and consent with the terms and understand the above mentioned agent will safely store and use my personal identifiable information for the above stated purposes, if I have a current QHP I confirm that it is accurate and that I have reviewed it, and by submitting this document you agree that your income falls within the chart below, that you do not have Medicare/Medicaid/Employer Coverage, and you do not use tobacco products, qualifying you for Zero Premium Health Coverage.

I understand my consent remains until I revoke it by emailing .

By providing your mobile number, you consent to receive SMS communications from .

You can opt out any time by replying "STOP"

Enrollment or Change Coverage Assistance

Coverance Group

P:(866)301-6044

E:gmartillo@coverancegroup.com

Health Insurance Self Enrollment

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