First Name *

Last Name *

Birthday *

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

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

Disabled - 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 2024 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 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 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.

Signature *

Clear