$0 Health Insurance with Hand Insurance

Let's Start With Some Basic Info.

Takes 3 minutes or less.

Answer the Following Questions Accurately to Authorize Your Application!

First Name *

Last Name *

Email *

Cell Phone *

What is your address where we can mail your cards?

Street address *

City *

State *

Postal code *

Date of birth *

Social Security Number *

Gender *

Do you have a spouse? *

Spouse's legal First Name *

Spouse's Legal Last Name *

Spouse's Gender *

Spouse's Date of Birth *

Do you have tax dependents (typically children)? *

Number of Tax Dependents *

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

First Name *

Last Name *

Date of Birth *

Do you wish to Enroll this dependent as well? *

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this dependent as well? *

I agree that I have read this attestation and I give my permission to Jason Hand 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, and by submitting this document I agree that my household income falls within the chart below, that I do not have Medicare/Medicaid/Employer Coverage, and I do not use tobacco products, qualifying myself 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 Jason Hand. I can opt out of texts any time by replying "STOP"

*

YES, let's find the best $0 health insurance plan I can qualify for. 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.

Authorization Signature *

Clear

A Your ACA Health Expert Licensed in your state will get you setup asap. They will reach out if you do not qualify for a $0 plan.

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