Answer The Following Questions To Apply For 2024 Health Insurance

Full Name *

Email *

Phone Number *

Home Address

Street Address *

State *

Zip Code *

City *

Primary Date Of Birth *

Social Security Number *

Marital Status *

Spouse First Name *

Spouse Last Name *

Spouse Date of Birth *

Spouse Gender *

Spouse SSN *

Do You Have Any Dependents Living At Home *

Yes

Dependent 1 Full Legal Name *

Dependent 1 Date of Birth *

TD 1 Enroll *

Do You Have A 2nd Dependent? *

Yes

Dependent 2 Full Name *

TD 2 Date of Birth *

TD 2 Enroll *

Do You Have A 3rd Dependent? *

Yes

Dependent 3 Full Name *

TD 3 Date of Birth *

TD 3 Enroll *

Do You Have A 4th Dependent? *

Yes

Dependent 4 Full Name *

TD 4 Date of Birth *

TD 4 Enroll

Do You Have A 5th Dependent? *

Yes

Dependent 5 Full Name *

TD 5 Date of Birth *

TD 5 Enroll *

Employer Name

Estimated Monthly Income

I agree that I have read this attestation and I give my permission to Kallin Iwasaki to serve as my broker for myself and my household, for the purposes of enrollment in a qualified Health Plan offer 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, if I have a current QHP I confirm that it is accurate and that I have reviewed it, and by submitting this document you agree that your income falls within the chart below, that you do not have Medicare/Medicaid/Employer Coverage, and you do not use tobacco products, qualifying you for Zero Premium Health Coverage.

I understand my consent remains until I revoke it by emailing kallin@defenderhealthinsurance.com.

By providing your mobile number, you consent to receive SMS communications from Kallin Iwasaki. You can opt out any time by replying "STOP"

Authorization Date *

Authorization Signature - I authorize Kallin Iwasaki to be my Agent of Record each month and re-enroll me in the best plan during Open Enrollment if my current plan is discontinued until I revoke consent. *

Clear