First Name *

Last Name *

Birthday *

Cell Phone *

Email Address *

Gender *

Are you pregnant or plan on becoming pregnant? *

Yes

Residential Address *

Line 2 of Street AddressStreet Address 2

City *

State *

Zip *

Is your mailing address the same? *

Yes

What is your Mailing Address? *

Tobacco User *

Yes

Select YES if you've used tobacco 4 or more times a week for the past 6 months. You may pay more for insurance, but if you get a related illness and do not report you are tobacco user, your insurance can deny you coverage.

What is your Marital Status *

Please complete information even if your spouse does not need coverage

Spouse's Name *

Spouse's DOB *

Spouse's SSN *

Spouse's Employment *

Employed

Umemployed

Social Security Benefits

Spouse's 2024 Estimated Annual Income *If Any

Does your spouse need health insurance?

Yes, add my spouse to this policy

Will you be filing taxes jointly with your spouse for 2024? *

Yes

What is your current working status? *

Employed

Unemployed

Receiving Social Security

Employer Name *

Estimated 2024 Annual Income

Does your employer offer you insurance? *

Yes

Socail Security Income Amount *

How often do you get this amount? *

Do you currently have Medicare? *

Yes

What is your estimated total annual income for 2024?

$0 - I estimate my annual income for 2023 to be $0

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

Will you claim any dependents on your taxes? *

Yes

Please provide this information even if your dependents do not need coverage

Dependent 1 *

Full Name
Date of Birth
SSN
Gender

Dependent 1 Coverage *

Yes, add this this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

Dependent 2 *

Full Name
Date of Birth
SSN
Gender

Dependent 2 Coverage *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

Dependent 3 *

Full Name
Date of Birth
SSN
Gender

Dependent 3 Coverage *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

Dependent 4 *

Full Name
Date of Birth
SSN
Gender

Dependent 4 Coverage *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

Dependent 5 *

Full Name
Date of Birth
SSN
Gender

Dependent 5 Coverage *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

Dependent 6 *

Full Name
Date of Birth
SSN
Gender

Dependent 6 Coverage *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

Dependent Names & Gender (press enter after each gender) *

Dependent Birthdays (press enter after each DOB) *

Dependent SSNs (press enter after each SSN) *

Do all of these dependents need covered on this policy? *

Yes

Do you have currently have Health Insurance? *

Yes

What kind of insurance do you have? *

Medicare Card Number *

Part A Effective Date

Part B Effective Date

Do you have a Primary Care Doctor you see regularly? *

Yes

Primary Care Doctor's Full Name *

What city are they located in? *

Do have any specialist you see? *

Yes

Please list all Specialist Names and Cities (press enter to after each for multiple) *

Do you take any prescription medicine? *

Yes

Please list all prescription medicine you take: *

Preferred Pharmacy

Your Social Security Number

By checking this box you are giving Schopmeyer Medicare, Health & Life the permission to finish processing your Health Insurance Marketplace application. You also agree to Schopmeyer Medicare, Health & Life becoming your Agent of Record with your health insurance provider through the Health Insurance Marketplace. Additionally, by signing this form, I understand any agent currently designated on this policy, will be removed, and the new agent being added will remain in effect until revoked or replaced in writing. I agree to allow my information and that of any listed individuals on the application to be retrieved and used from government data sources for the purpose of this application. I understand that providing false information may result in penalties under federal law and that I may be asked to provide proof of eligibility for a Special Enrollment Period if applicable. I also give consent for the Marketplace to use my income data for the next 5 years to determine eligibility for assistance in future years, and understand that I can opt out at any time. I acknowledge that I may be ineligible for a premium tax credit if found eligible for other health coverage, and that I must contact the Marketplace to end coverage and premium tax credit in such a case. I understand that I am required to file a federal income tax return for 2024, and that any changes in my circumstances may impact my ability to receive the premium tax credit. I agree to notify the program of any changes in my information and understand that failure to do so may affect the eligibility of others in my household. I am signing this application under penalty of perjury, acknowledging that I have provided true answers to the best of my knowledge. I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from Schopmeyer Medicare, Health & Life.

Signature *

Clear