First Name
*
Middle Initial
Last Name
*
Date of birth
*
Address
*
Street Address
*
City
*
State
*
Postal Code
*
County
*
Please Enter Your County
Mailing Address the same as Physical Address?
Yes
No
Mailing - Address
Mailing - City
Mailing - State
Postal Code - Mailing
Phone
*
Email
*
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Social Security Number
*
Format XXX-XX-XXXX
Height
*
Weight
*
Adjusted Gross Income
Policy Holder Income
*
$
This is Adjusted Gross Income or if you are W-2 Gross Income!
Do you need coverage?
YES
NO
Do you have a Spouse you claim taxes together?
YES
NO
ACA Spouse Info
Full Name
Date of Birth
SSN
Gender
Phone#
Email
ACA Spouse Annual Income
*
$
ACA Spouse Need Coverage
YES
NO
Do you have Dependent Children you claim on taxes?
*
YES
NO
ACA Dependent 1 Info
Full Name
Date of Birth
SSN
Gender
ACA Dependent 1 Annual Income
*
$
Enter $0 if no income!
ACA Dependent 1 Needs Coverage
YES
NO
Do you claim a 2nd Dependent on your taxes?
YES
NO
ACA Dependent 2 Info
Full Name
Date of Birth
SSN
Gender
ACA Dependent 2 Annual Income
*
$
ACA Dependent 2 Need Coverage
YES
NO
Do you claim a 3rd Dependent on your taxes?
YES
NO
ACA Dependent 3 Info
Full Name
Date of Birth
SSN
Gender
ACA Dependent 3 Annual Income
*
$
ACA Dependent 3 Need Coverage
*
YES
NO
Do you claim a 4th Dependent on your taxes?
YES
NO
ACA Dependent 4 Info
Full Name
Date of Birth
SSN
Gender
ACA Dependent 4 Annual Income
$
ACA Dependent 4 Need Coverage
YES
NO
Do you claim a 5nd Dependent on your taxes?
YES
NO
ACA Dependent 5 Info
Full Name
Date of Birth
SS#
Gender
ACA Dependent 5 Annual Income
*
$
ACA Dependent 5 Need Coverage
*
YES
NO
Thank you,
Please submit
