First Name *

Last Name *

Cell Phone *

Email Address *

Gender *

Male

Female

Are you pregnant or plan on becoming pregnant? *

Yes

Residential Address *

Street 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

Do you currently have Medicare? *

Yes

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

Medicare Card Number *

Part A Effective Date

Part B Effective Date

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) *

Please list all prescription medicine you take: *

Preferred Pharmacy

Your Social Security Number *

By checking this box you are giving Bobby Brock Insurance the permission to finish processing your Health Insurance Marketplace application. You also agree to Bobby Brock Insurance 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 Bobby Brock Insurance.