ACA form Local Staffing – Bestpolicy.co

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Form Clue Cert

Do You Qualify for No Cost Health Insurance

I give permission to Best Policy, LLC, My Health Insurance, LLC, and Insurely, LLC and their affiliates to access and/or create my application for health insurance on the Federally Facilitated Marketplace (FFM) based on the information I am providing below. I also give them consent to contact me through: Email, SMS or by Phone.*

Yes, I give Permission.

Main Applicant Date of Birth*

Month

Day

Year

If you are under the age of 19 you will not qualify

Age*

You need to be at least 19 year old to Continue

Your Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Select State*

Do you currently have any of the following?*

None of the below. I want Best Policy or any of its affiliates to enroll me.

Medicare

Medicaid or Chip Coverage

Veterans Coverage

Employer Coverage

Current ACA Marketplace Plan

I'm not certain

By providing your phone number and submitting this form, you consent to receive Agent and automated text messages regarding ACA (Affordable Care Act) insurance updates, enrollment information, and related offers.*

Yes, I give Permission.

Message Frequency: You may receive recurring messages based on your interactions and ACA enrollment cycle. These communications may be sent using an automated dialer and/or pre-recorded audio.
Msg & Data Rates: Standard message and data rates may apply. Check with your mobile carrier for details.
Opt-Out: You can opt out at any time by replying STOP to any text message. This will unsubscribe you from further communications.
HELP: For assistance, reply HELP to any message or contact our support team at [email protected]
Your consent to receive text messages is not a condition of purchasing any goods or services.

Are you sure you have Medicare?

If you have MEDICARE we will not be able to help you, if please choose another option if you want to continue.

Are you sure you have Medicare?

if you have Medicaid, you could run the risk of losing it if approved for this subsidy

Are you sure you have Medicare?

If you have Veterans Coverage we will not be able to help you, if please choose another option if you want to continue.

Are you sure you have Medicare?

If you have Employer Coverage we will not be able to help you, if please choose another option if you want to continue.

Your State is not currently supported

Based on the information you have shared. we have found this carriers who have zero cost plans!

Which carrier are you interested in?

Plan Selection*

Social Security Number*

You must be a US Citizen, U.S. National, or have certain legal immigration statuses to be accepted into a Marketplace plan. See if you’re eligible https://www.healthcare.gov/quick-guide/eligibility/. Debe ser ciudadano estadounidense, nacional estadounidense o tener ciertos estados migratorios legales para ser aceptado en un plan del Mercado.

Please note:
If the SSN provided does not belong to you, is invalid, or results in a mismatch, we will not be able to process your enrollment.

Gender*

Immigration Status*

U.S. Citizen

Permanent Resident (Green Card holder)

Temporary Resident

Asylum Seeker

Refugee

Other

Please provide your legal immigration status and relevant identification number.

Alien Number (A-Number)

(If you are a permanent resident or have a different immigration status that provides an Alien Number, please input it here.)

Employment Authorization Card Number (EAD Number)

(If you have an Employment Authorization Card, please input the number here.)

Please Upload your Employment Authorization Card Below

Employment Authorization Card Front*

Max. file size: 50 MB.

Employment Authorization Card Back*

Max. file size: 50 MB.

Tax Filing Status*

Single

Married Filing Jointly (married couples must file jointly to qualify)

Spouse Name*

Spouse Last name*

Date of Birth**

MM slash DD slash YYYY

Spouse Gender

Spouse Social Security Number*

Spouse Income*

Spouse Consent*

Please add this Dependant to my health insurance policy

Will you be claiming any dependents on your taxes in 2025?*

Yes

Dependant 1 Name*

Dependant 1 Last name*

Dependant 1 Date of Birth**

MM slash DD slash YYYY

Dependant 1 Gender

Dependant 1 Social Security Number*

Dependant 1 Income*

Dependant 1 Consent*

Please add this Dependant to my health insurance policy

Please select the value closest to your estimated 2025 income*

Income Verification*

By clicking the checkbox below, I hereby provide consent and authorization to My Health Insurance, LLC and Best Policy, LLC and/or its affiliates to submit my estimated income as stated. I realize I cannot predict the future, but the income provided is my best guess and made in good faith. I also provide consent and authorization to My Health Insurance, LLC and Best Policy, LLC and/or its affiliates to submit an income verification letter on my behalf if required by the marketplace.

Yes, I Agree

Any changes in the last 60 days or upcoming Loss of Coverage?

Loss of Coverage

Loss Coverage*

MM slash DD slash YYYY

Other:

B. Release from incarceration

Release from incarceration*

MM slash DD slash YYYY

C. Change of Residence

Moved*

MM slash DD slash YYYY

Former Zipcode

Zip code of your last Address

D. Household Changes

D. Change in marital status

D. Change in marital status Options

Marriage

Divorce

Birth of a child.

Adoption or foster care placement.

Death in the household that affects coverage.

Household Changes*

MM slash DD slash YYYY

Consent Acknowledgement*

By clicking “I Agree”, I am providing my electronic signature expressly authorizing My Health Insurance, LLC and Best Policy, LLC and/or its affiliate to contact me by email, phone or text (including an automatic dialing system or artificial/pre-recorded voice) at the home or cell phone number above. I understand I am not required to sign/agree to this as a condition to purchase. I give my permission to My Health Insurance, LLC and Best Policy, LLC and/or its affiliates to serve as the health insurance agency, agent, and/or broker 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 agency, agent, and/or broker 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: 1- Searching for an existing Marketplace application; 2- 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; 3- Providing ongoing account maintenance and enrollment assistance, as necessary; or 4- Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the agency, agent, and/or broker will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agency, agent, and/or broker will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provided for entry on my Marketplace eligibility and enrollment application is 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 Agency, agent, and/or broker 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 emailing [email protected]

Yes, I Agree

Consent to Enrollment*

Disclaimer for Health Insurance Applications
Please note that due to circumstances beyond our control, we cannot guarantee the processing time for your application. However, we strive to handle your application as promptly as possible. If we require further clarification or additional information, one of our knowledgeable agents will contact you using the method you specified in your application.
We are committed to meeting your healthcare and ancillary insurance needs and aim to become the agency you are proud to recommend to your family and friends. If a prompt submission of your application is necessary or you have any questions before submitting your application, please contact us at 385-308-5251 (available from 9 AM to 9 PM Eastern) or via email at [email protected].

Yes, I Agree

First Name:

Last Name:

Consent Signature*

Authorization and Tax attestation*

If another agent goes into your application and changes the agent of record, we will no longer have access to your policy. Should that happen, do you give permission to our agency to go back in and be listed as agent of record? | Renewal Authorization: Open Enrollment begins Nov 1st of every year. This is when we need to re-enroll your health policy with us. Do you authorize us to auto-renew your insurance policy and change your plan to a different company if needed to ensure your plan remains $0 even if there is a different network of doctors? This allows us to remain agent of record and ensure your coverage does not lapse. | Tax Attestation - Please confirm that you: (1) Agree to allow the Marketplace to use your income data, including information from tax returns, for the next 5 years; (2) understand that you are not eligible for a premium tax credit if found eligible for other qualifying health coverage, such as Medicaid, CHIP, or a job-based health plan; (3) understand that if you become eligible for other qualifying health coverage, you must contact the Marketplace to end your coverage and premium tax credit; (4) understand if the income on your tax return is higher than the amount of income on your application, you may owe additional federal income tax. I acknowledge that to participate in the Affordable Care Act program, I am required to file taxes for any year in which I have been enrolled. Failure to do so may result in loss of future eligibility

Yes, I Agree

Verification of Information & Submit Application*

I have reviewed the above application information and attest to its accuracy, You agree that you have provided true answers to all of the questions to the best of your knowledge, and you know you may be subject to penalties under federal law if you intentionally provide false information. You attest that your estimated income for 2025 will be at least the Federal Poverty Limit for your state and household requirements . You agree to notify us as soon as you become aware of any changes to expected income per month that you provided above. Failure to notify us of any changes may result in your eligibility being affected. A Best Policy or My Health Insurance licensed agent will call you as we process your enrollment. You authorize Best Policy or My Health Insurance to submit an application on your behalf even if we cannot reach you immediately.

HEALTH INSURANCE CONSENT AND ACKNOWLEDGMENT FORM AGENT INFORMATION

The following agents are authorized for health insurance services:
Jace Austin (NPN: 18002255) – [email protected]
Madaline Purser (NPN: 20990394) – [email protected]
Samantha Gulledge (NPN: 21311089) – [email protected]
Tanner J Purser (NPN: 20991953) – [email protected]
Whitney D Stump (NPN: 20998127) – [email protected]
Chalyn Jones (NPN: 21000913) – [email protected]
Ana Denise Delgado (NPN: 20971760) – [email protected]
Christine Munns (NPN: 21359487) – [email protected]
Lea Raddi (NPN: 20785476) – [email protected]
Collin Munns (NPN: 2134809) – [email protected]
Alicia Gardner (NPN: 22054798) – [email protected]
Matt Gardner (NPN: 21753377) –[email protected]

Yes, I Agree

Signature*

By signing, I grant permission to act on my behalf and that of my entire household in matters related to enrollment in a Qualified Health Plan via the Federally Facilitated Marketplace. This authorization also extends to any authorized representative or power of attorney acting on my behalf. The agents empowered by this agreement are My Health Insurance, LLC and Best Policy Co and/or its affiliates. These agents are authorized to locate existing Marketplace applications, complete applications for eligibility in various plans and programs, provide necessary ongoing maintenance, and respond to inquiries about my application from the Marketplace. I understand and agree that my personally identifiable information will be accessed and used solely for the objectives specified in this document. I have reviewed and verified that the information included in this application is correct to the best of my knowledge. I am under no obligation to disclose additional personal or health-related information beyond what is required for these applications. My consent remains effective until I choose to revoke it. For any modifications or to revoke this consent, I can email [email protected]

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Do You Qualify for No Cost Health Insurance

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