Short-Health-Form | LifeandHealthForAll

This is a Short Form For Those Who Already Have/Had Marketplace coverage

This is a much shorter form for those who have already had ACA/"Affordable Care Act"/Marketplace/Trump Care/Obama care/Healthcare.gov plans, you can just fill this quick form out. If you do not or have never had this kind of coverage then you would want to fill out our longer more detailed form at the link/button at the bottom for us to qualify you instead!

First Name

Last Name

Phone Number

Birthday

Estimated Annual Income

Select an Address

Authorization & Consent

I give my permission to Daniel Oliver to serve as the health insurance Agent or broker for myself and my entire household if applicable. This allows the agent to enroll me, and my family, in a Qualified Health Plan on the Federally Facilitated Marketplace. By agreeing to this, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following:  1. I authorize my healthcare provider to collect, use and Search for an existing Marketplace application.  2. Complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs.  3. Provide ongoing account maintenance and enrollment assistance.  4. Respond to inquiries from the Marketplace regarding my application.  5. I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.  6. I confirm that the information I provide on my application will be accurate to the best of my knowledge.  7. By submitting this document I agree that my household income falls within the chart below, that I do not have Medicare, Medicaid or Employer Coverage. I understand that I am not obligated to share additional personal information beyond what is required for the application. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my Agent.  8. I acknowledge your request to enroll me in the most suitable health plan available based on your expertise. If zero premium plans are unavailable, I authorize you to enroll me in the next best available plan. I grant you access to my healthcare.gov account for submitting necessary information. By signing below, I confirm my understanding and agreement to the terms outlined in this attestation.  Agent of Record: Daniel Oliver NPN: 17832022 Phone Number: (903) 880-7346 Email Address: lifeandhealthforall1123@gmail.com    Authorization Signature - I authorize you to be my Agent of Record each month until I reach out to you and revoke or change my consent. You may also re-enroll me in the best plan during Open Enrollment if my current plan is discontinued, changes, or if it needs to be renewed.

I accept terms & conditionsView terms of use

Your Signature

Confirm the Date

Once you submit you will be redirected to a referral page where you can be paid $10 per referral, if you don't have any then feel free to close the next page!

Don't Need Health Insurance?

But Know Someone Who Does?

Referral Link

If you need health insurance & want to earn in our referral program. You can submit the application above and you will automatically be directed to our $10 referral program after you complete your Health Insurance Application.

If you have never had coverage through the marketplace then simply Click this link or press the button below to be qualified for coverage Instead.

Qualify