$0 Health Insurance Plan + Premium Tax Credit

*If you qualify

Answer the Following Questions Accurately to Authorize Your Application!

Total number of people to be enrolled

Please select yes or no
Please select your spouse's gender
Please select yes or no
Select your first dependent's gender
Please select yes or no
Select your second dependent's gender
Please select yes or no
Please select your third dependent's gender
Please select yes or no
Please select your fourth dependent's gender
Please select yes or no
Please select your fifth dependent's gender
Please select yes or no
Please select your sixth dependent's gender

Estimated household income

I give my permission to the agent listed below, or one of the designated agents listed below**, to serve as the health insurance agent or broker for myself and my entire household for purposes of enrollment in a Qualified Marketplace Health Plan. By consenting to this agreement, I also authorize said Agent, or his licensed designee to use the information provided by me in writing, electronically, or by telephone for the following purposes:

Your Agent: Nathan Wright

Phone Number: 615-908-2427

Email Address: [email protected]

Agent NPN: 17655994

SMS (Text Message) Consent:

By providing your mobile number, you consent to receive

SMS (text message) communications from Nathan Wright.

**Designated Agents:

Upon signing & submitting this document I am confirming I DO NOT currently have Medicare, Medicaid, Group, federally recognized Tribes, or ANCSA shareholder Insurance Coverage.

By consenting to this agreement, I also authorize said Agent to use the information provided by me in writing, electronically, or by telephone for the following purposes:

I authorize the agent listed to search for an existing Marketplace application: 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. Providing ongoing account maintenance and enrollment assistance, as necessary. Responding to inquiries from the Marketplace regarding my Marketplace application for the next 60 months.

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 at the email address or phone number provided below. 

Msg & data rates may apply. You can opt out at any time by replying 'STOP'. By submitting this document, you agree the above information is true and accurate. Please note, not all applicants qualify for the subsidies and/or $500 Rewards. However, our insurance plans offer a range of benefits that could be advantageous for you. Upon signing & submitting this document, I am confirming I DO NOT currently have Medicare, Medicaid, Group, federally recognized Tribes, or ANCSA shareholder Insurance Coverage. We cannot take any actions that jeopardize these types of coverage.

Clear

Answer the Following Questions Accurately to Authorize Your Application!

Total number of people to be enrolled

Please select yes or no
Please select your spouse's gender
Please select yes or no
Select your first dependent's gender
Please select yes or no
Select your second dependent's gender
Please select yes or no
Please select your third dependent's gender
Please select yes or no
Please select your fourth dependent's gender
Please select yes or no
Please select your fifth dependent's gender
Please select yes or no
Please select your sixth dependent's gender

Estimated household income

I give my permission to the agent listed below, or one of the designated agents listed below**, to serve as the health insurance agent or broker for myself and my entire household for purposes of enrollment in a Qualified Marketplace Health Plan. By consenting to this agreement, I also authorize said Agent, or his licensed designee to use the information provided by me in writing, electronically, or by telephone for the following purposes:

Your Agent: Nathan Wright

Phone Number: 615-908-2427

Email Address: [email protected]

Agent NPN: 17655994

SMS (Text Message) Consent:

By providing your mobile number, you consent to receive

SMS (text message) communications from Nathan Wright.

**Designated Agents:

Upon signing & submitting this document I am confirming I DO NOT currently have Medicare, Medicaid, Group, federally recognized Tribes, or ANCSA shareholder Insurance Coverage.

By consenting to this agreement, I also authorize said Agent to use the information provided by me in writing, electronically, or by telephone for the following purposes:

I authorize the agent listed to search for an existing Marketplace application: 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. Providing ongoing account maintenance and enrollment assistance, as necessary. Responding to inquiries from the Marketplace regarding my Marketplace application for the next 60 months.

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 at the email address or phone number provided below. 

Msg & data rates may apply. You can opt out at any time by replying 'STOP'. By submitting this document, you agree the above information is true and accurate. Please note, not all applicants qualify for the subsidies and/or $500 Rewards. However, our insurance plans offer a range of benefits that could be advantageous for you. Upon signing & submitting this document, I am confirming I DO NOT currently have Medicare, Medicaid, Group, federally recognized Tribes, or ANCSA shareholder Insurance Coverage. We cannot take any actions that jeopardize these types of coverage.

Clear

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