SIGN UP ONLINE

How many people need coverage? *

- select an option -

1
2
3
4
5
6
7
8
9
10
No elements found. Consider changing the search query.
List is empty.

SIGN UP ONLINE

MAIN APPLICANT INFORMATION

First Name *

Last Name *

Cell Phone Number *

Email *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

SIGN UP ONLINE

Do you want to apply for a subsidy to pay for your insurance?

Yes

No

SIGN UP ONLINE

ADDRESS INFORMATION

Address (NOT your P.O. Box) *

City *

State *

Postal code *

County (Plans Vary by County) *

HOUSEHOLD INFORMATION

Social Security - Main Applicant

IMPORTANT (Please Read): If you choose NOT to provide your Social Security Number today, you will have 90 days to provide your social to the Marketplace. If they do not receive your information within 90 days. The Marketplace will terminate your insurance We'll send reminders via email, text and phone calls once you've received your ID cards.

Job Seeking

If making less than $1100/mo, I agree I am looking for a job making minimum wage or better

Does Anyone Use Tobacco? If so who?

Do you currently have Medicare, Medicaid, an employer policy or V.A. benefits? (You will NOT qualify for an ACA subsidy if you qualify for Medicaid/ Medicare/ Employer coverage or VA plan.

Any Other Current Insurance? *

Yes

No

I attest that from this day forward (AGENT NAME), NPN (AGENT NPN), will be the agent of record for my healthcare.gov insurance plan with the marketplace and will only be replaced by another agent if written notice is submitted to him.

Healthcare.gov Access *

Yes

No

Do you understand that if you’re not eligible for a $0 plan we will enroll you in the cheapest plan that is still affordable? (If you decide that you do not want this plan simply don’t pay the bill or call the insurance company to cancel.)

Free Plan Eligibility *

Yes

No

Are you married?

Yes

No

SIGN UP ONLINE

Yes I'm Married:

Spouse Name

Does Spouse Need Coverage?

Yes

No

Spouse Social Security Number (no dashes)

IMPORTANT (Please Read): If you choose NOT to provide your Social Security Number today, you will have 90 days to provide your social to the Marketplace. If they do not receive your information within 90 days. The Marketplace will terminate your insurance We'll send reminders via email, text and phone calls once you've received your ID cards.

Name of Employer for Spouse

Spouse Expected Income Per Month (Be Accurate - Income Will Be Verified By Healthcare.gov)

$

SIGN UP ONLINE

Do You Claim Any Dependents?

- select -

0
1
2
3
4
5
6
7
8
9
No elements found. Consider changing the search query.
List is empty.

SIGN UP ONLINE

Please Add Info for Dependent #1

Full Name
Relationship to Applicant
Date of Birth
Gender
Height
Weight
Social Security Number
Do They Need Coverage?

+++ Socials are only needed if dependent is applying for insurance +++

Need to add a 2nd Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #2

Full Name
Relationship to Applicant
Date of Birth
Gender
Height
Weight
Social Security Number
Do They Need Coverage?

*** Socials are only needed if dependent is applying for insurance ***

Need to add a 3rd Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #3

Full Name
Relationship to Applicant
Birthday
Gender
Height
Weight
Social Security Number
Do They Need Coverage?

*** Socials are only needed if dependent is applying for insurance ***

Need to add a 4th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #4

Full Name
Relationship to Applicant
Date of Birth
Gender
Height
Weight
Social Security Number
Do They Need Coverage?

*** Socials are only needed if dependent is applying for insurance ***

Need to add a 5th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #5

Full Name
Relationship to Applicant
Date of Birth
Gender
Height
Weight
Social Security Number
Do They Need Coverage?

*** Socials are only needed if dependent is applying for insurance ***

Need to add a 6th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #6

Full Name
Relationship to Applicant
Date of Birth
Gender
Height
Weight
Social Security Number
Do They Need Coverage?

*** Socials are only needed if dependent is applying for insurance ***

Need to add a 7th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #7

Full Name
Relationship to Applicant
Date of Birth
Gender
Height
Weight
Social Security Number
Do They Need Coverage?

*** Socials are only needed if dependent is applying for insurance ***

Need to add a 8th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #8

Full Name
Relationship to Applicant
Birthday
Gender
Height
Weight
Social Security Number
Do They Need Coverage?

*** Socials are only needed if dependent is applying for insurance ***

Need to add a 9th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #9

Full Name
Relationship to Applicant
Date of Birth
Gender
Height
Weight
Social Security Number
Do They Need Coverage?

*** Socials are only needed if dependent is applying for insurance ***

We understand how important it is to continue seeing the providers you wish. Please list the names of providers below and we will do our best to ensure we find a plan that allows you to continue seeing them.

Please list the names of any healthcare providers that you would like to continue seeing and ensure they are in the network.

List the names of any of prescription drugs taken by members listed.

SIGN UP ONLINE

PLAN CHOICE

Check Box Below: *

YES! I give permission to apply for free health insurance!

AGREEMENTS

Please read the attestations below and sign if you agree.

I agree to have my information used and retrieved from government data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from government data sources.

I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage. Renewal of coverage

To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.

TAX ATTESTATION

I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: I must file a federal income tax return for the 2024 tax year.

I MUST FILE A FEDERAL INCOME RETURN FOR THE 2024 TAX YEAR.

If I’m married at the end of 2024, I must file a joint income tax return with my spouse. I also expect that: No one else will be able to claim me as a dependent on their 2024 federal income tax return. I’ll claim a personal exemption deduction on my 2024 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.

IF ANY OF THE ABOVE CHANGES

I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2024 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

PLEASE READ ATTESTATIONS BELOW BEFORE YOU SIGN AND SUBMIT YOUR APPLICATION:

I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by texting Burton Hayden at (956) 246-4123. I know a change in my information could affect eligibility for member(s) of my household.

If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.

I have read and agree to the terms above *

YES

NO

Broker Consent Agreement

I give my permission to Burton Hayden of Hercules Health Solution to serve as the health insurance agent or broker for myself and my entire household (if applicable), for the 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 phone only for one or more of the following:

Searching for an existing Marketplace application.
Completing an application for eligibility and enrollment in a qualified marketplace plan.
Providing ongoing account maintenance and enrollment premium.
Responding to inquiries from the marketplace regarding my application.

By Signing Below I Attest to the Following:

I understand that the agent will not use or share my personally identifiable information (PII) for any other purposes other than those listed above. The agent will ensure that my PII is kept private and safe when collecting, storing, and using for the stated purposes above.

I confirm that the information I provide for entry on my marketplace eligibilty and enrollment application will be true to the best of my knowledge.

I confirm that I have reviewed my completed application and all information is accurage.

I understand that I do not have to share additional information about myself or my health with my agent beyond what is required on the application for eligibility and enrollment purposes. I understand my consent remains in effect until I revoke it, and may revoke or modify my consent at any time by contacting my agent or through my HealthSherpa dashboard.

IF AGREE TO ABOVE STATEMENT(S), PLEASE SIGN IN BOX TO AUTHORIZE SUBMISSION OF APPLICATION *

Full Name *

Today's Date *

Name of Primary Writing Agent/ Broker: Burton Hayden

National Producer Number: 19737613

Phone Number: (956) 246-4123

Email Address: herculeshealthsolutions@gmail.com

0%