Lets start with some basic info

Takes 3 minutes or less.

Answer the Following Questions Accurately to Authorize Your Application!

First Name *

Last Name *

Email *

Phone *

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

What is your address where we can mail the cards?

Street Address *

City *

State *

Zip code *

Primary Date of Birth MM-DD-YYYY *

Please remember to switch the birth year

Primary Applicant's Social Security Number *

Do you have a Spouse?

Yes

No

Spouse Legal First Name *

Spouse Legal Last Name *

Spouse's Gender *

Spouse's Date of Birth MM-DD-YYYY *

Spouse Social Security Number

What is your employment status? *

Employed

Unemployed

Other

Do You Have Any Dependents? *

Yes

No

Dependent 1 Full Legal Name *

Dependent 1 Gender *

Dependent 1 Date of Birth MM-DD-YYYY *

Dependent 1 Social Security Number

Do You Have a 2nd Dependent? *

Yes

No

Dependent 2 Full Legal Name *

Dependent 2 Gender *

Dependent 2 Date of Birth MM-DD-YYYY *

Dependent 2 Social Security Number

Do You Have a 3rd Dependent? *

Yes

No

Dependent 3 Full Legal Name *

Dependent 3 Gender *

Dependent 3 Date of Birth MM-DD-YYYY *

Dependent 3 Social Security Number

Do You Have a 4th Dependent? *

Yes

No

Dependent 4 Full Legal Name *

Dependent 4 Gender *

Dependent 4 Date of Birth MM-DD-YYY *

Dependent 4 Social Security Number

Do You Have a 5th Dependent?

Yes

No

Dependent 5 Full Legal Name *

Dependent 5 Gender *

Dependent 5 Date of Birth MM-DD-YYYY *

Dependent 5 Social Security Number

If you are currently enrolled in a medicare or medicaid plan you won't qualify.

If you recently lost coverage you can continue the application.

Are you currently enrolled in medicare OR medicaid? *

Yes

No

Just lost coverage

I agree that I have read this attestation and I give my permission to Financially Fluent 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 [email protected].

By providing your mobile number, you consent to receive SMS communications from Financially Fluent. You can opt out any time by replying "STOP"

Authorization Date *

Signature Authorization Signature - I authorize you to be my Agent of Record each month until I revoke consent and re-enroll me in the best plan during Open Enrollment if my current plan is discontinued *

Clear

1. Consent & Review Consent Form

Searching 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; or
Responding to inquiries from the Marketplace regarding my Marketplace application.

I, give my permission to Financially Fluent NPN: 20835665 to serve as the health insurance agency 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:

I confirm that the information I provide 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 modify my consent at any time by written documentation or verbal declaration.

I understand that the Agency 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.

Full Name *

Signature *

Clear

Term & Conditions