Mere Benefits is a DBA of Health Wealth Simplified LLC, managed by Kate Spilsbury, Licensed Insurance Agent #9527400

First Name *

Last Name *

Phone *

Email *

Address

Street Address

City

State

Country

Postal code *

County *

Social Security Number *

Please enter your Projected Annual Household Income for 2026.

(Typically, In line 11 of your previous year's tax return.)

For more information on how to project your income, please click HERE to check the guide

Who referred you? (If no one please ignore this form field)

I consent to receive communications from Health Wealth Simplified, LLC DBA Mere and Mere Benefits, including but not limited to text messages (SMS/MMS), emails, phone calls, and ringless voicemails. These communications may include information about health insurance plans, policy updates, educational events, and promotional offers. Some communications may be automated or sent using AI tools. Message frequency may vary. Message and data rates may apply.
I understand that I may withdraw my consent at any time by replying STOP to a text or using the unsubscribe link in an email. I also understand that withdrawing consent means Mere will no longer be able to service my insurance needs, as electronic communication is required for our client relationship. Consent is required for us to provide services, but is not required to purchase insurance from any carrier. We will not send marketing messages outside of legally permitted hours. See our Privacy Policy at https://www.merebenefits.com/privacy-policy for details.

Virtual Meeting Disclosure:
I acknowledge that some virtual meetings may be recorded and transcribed using Fathom AI Notetaker, a HIPAA-compliant tool used by Mere to support accurate documentation. This platform operates under a Business Associate Agreement and stores data securely. Meeting summaries or transcripts may be retained and used only for service-related purposes.

Agent's Name *

Consent

I authorize Kate Spilsbury to be my health insurance agent for myself and my household. This consent allows Kate Spilsbury to assist me with my application and enrollment in a Qualified Health Plan on the Federally Facilitated Marketplace.
By agreeing to this, I give permission for Kate Spilsbury to use my confidential information for the following purposes:

Search for an existing Marketplace application.
Prepare and complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs, using only the information I provide.
Provide ongoing account maintenance and enrollment assistance.
Respond to Marketplace inquiries regarding my application in order to resolve issues or complete required steps.
Access my Healthcare.gov account solely to submit or update information with my knowledge and based on information I provide.

Important Acknowledgements

I understand that no plan will ever be selected, changed, or submitted without my explicit verbal or written approval.
All enrollment decisions will be reviewed and confirmed by me during my appointment.
I must be present and actively participating in the enrollment meeting for my plan to be submitted.
My agent cannot advise me on what income to report. I am responsible for providing accurate income and household information to the best of my knowledge.
My personal information will be kept private and secure and used only for the purposes outlined in this consent.
I am not required to share information beyond what is necessary for the application.
I may revoke or modify this consent at any time by emailing info@merebenefits.com, and revoking consent will not affect my eligibility for coverage.

By signing below, I confirm my understanding of and agreement to the terms outlined in this attestation.
Agent of Record: Kate Spilsbury
NPN: 9527400
Phone Number: (904) 654-5450
Email Address: info@merebenefits.com

Sign Here (You may use your finger if you are on mobile/tablet device) *

Clear

Consent

I authorize Michael Wakefield to be my health insurance agent for myself and my household. This consent allows Michael Wakefield to assist me with my application and enrollment in a Qualified Health Plan on the Federally Facilitated Marketplace.

By agreeing to this, I give permission for Michael Wakefield to use my confidential information for the following purposes:

Search for an existing Marketplace application.
Prepare and complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs, using only the information I provide.
Provide ongoing account maintenance and enrollment assistance.
Respond to Marketplace inquiries regarding my application in order to resolve issues or complete required steps.
Access my Healthcare.gov account solely to submit or update information with my knowledge and based on information I provide.

Important Acknowledgements

I understand that no plan will ever be selected, changed, or submitted without my explicit verbal or written approval.
All enrollment decisions will be reviewed and confirmed by me during my appointment.
I must be present and actively participating in the enrollment meeting for my plan to be submitted.
My agent cannot advise me on what income to report. I am responsible for providing accurate income and household information to the best of my knowledge.
My personal information will be kept private and secure and used only for the purposes outlined in this consent.
I am not required to share information beyond what is necessary for the application.
I may revoke or modify this consent at any time by emailing michael@merebenefits.com, and revoking consent will not affect my eligibility for coverage.

By signing below, I confirm my understanding of and agreement to the terms outlined in this attestation.

Agent of Record: Worley Richards
NPN: 7918700
Phone Number: (904) 654-5450
Email Address: michael@merebenefits.com

Sign Here (You may use your finger if you are on mobile/tablet device) *

Clear

Consent

I authorize Worley Richards to be my health insurance agent for myself and my household. This consent allows Worley Richards to assist me with my application and enrollment in a Qualified Health Plan on the Federally Facilitated Marketplace.

By agreeing to this, I give permission for Worley Richards to use my confidential information for the following purposes:

Search for an existing Marketplace application.
Prepare and complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs, using only the information I provide.
Provide ongoing account maintenance and enrollment assistance.
Respond to Marketplace inquiries regarding my application in order to resolve issues or complete required steps.
Access my Healthcare.gov account solely to submit or update information with my knowledge and based on information I provide.

Important Acknowledgements

I understand that no plan will ever be selected, changed, or submitted without my explicit verbal or written approval.
All enrollment decisions will be reviewed and confirmed by me during my appointment.
I must be present and actively participating in the enrollment meeting for my plan to be submitted.
My agent cannot advise me on what income to report. I am responsible for providing accurate income and household information to the best of my knowledge.
My personal information will be kept private and secure and used only for the purposes outlined in this consent.
I am not required to share information beyond what is necessary for the application.
I may revoke or modify this consent at any time by emailing worley@merebenefits.com, and revoking consent will not affect my eligibility for coverage.

By signing below, I confirm my understanding of and agreement to the terms outlined in this attestation.

Agent of Record: Worley Richards
NPN: 7918700
Phone Number: (602) 606-7785
Email Address: worley@merebenefits.com

Sign Here (You may use your finger if you are on mobile/tablet device) *

Clear

Mere Benefits is a DBA of Health Wealth Simplified LLC, managed by Kate Spilsbury, Licensed Insurance Agent #9527400

Please make sure the spelling is accurate.

List of Doctors (Include Practice Name & Phone Number)

Please list the plans you know your provider accepts. Keep in mind that we won’t have time to call your provider, and online directories can sometimes be inaccurate. If it’s essential for you to keep your provider, we need to know exactly which carriers they accept.

Please click HERE for a list of helpful questions and talking points you can use when contacting your provider directly.

List of Plans your Provider accepts:

List of Medications (Include strength and how often)

People that need to be removed from your plan.

NOTE:

Social Security Number of ALL the household members on the application will be required AT THE TIME OF THE APPLICATION

People that need to be added to your plan.

What do you want to change for 2026? (if anything)

Is any of this information different than last years? *

Yes

Which Method Of Contact Do You Prefer? *

Phone Call

Text