Insurance Referral Form

Instructions

To sign up for free health insurance, complete this form, and we will forward your information to a licensed insurance agent in your state.

If we have questions or concerns about your application, we will call you by phone.

WHO REFERRED YOU? *

PLEASE UPLOAD A COPY OF YOUR ID *

FIRST NAME *

MIDDLE NAME

LAST NAME *

SUFFIX

PHONE - A VALID phone number that belongs to the primary insured. *

EMAIL -This field is not required but is VERY helpful. Do not use a fake email.

SOCIAL SECURITY NUMBER *

DATE OF BIRTH * +

GENDER *

Have you used tobacco 4 or more times a week in the past 6 months? *

NO

YES

ADDRESS - Physical address only. No P.O. Boxes. *

CITY *

STATE *

ZIP CODE *

COUNTY *

HOMELESSNESS - Are you experiencing homelessness? (An individual or family who lacks a fixed, regular, and adequate nighttime residence, such as those living in emergency shelters, transitional housing, or places not meant for habitation.) *

YES

NO

EMPLOYER - Type Self Employed if you work for yourself or are seeking a job. *

MONTHLY INCOME - The minimum income to qualify is $1,133 monthly. *

*

I UNDERSTAND THAT THIS APPLICATION IS BEING SUBMITTED TO THE MARKETPLACE TO OBTAIN NEW HEALTH INSURANCE COVERAGE.

*

I DO NOT CURRENTLY HAVE MEDICARE, MEDICAID, AN EMPLOYER POLICY, OR VETERANS BENEFITS.

Are you married? *

NO

YES

SPOUSE FIRST NAME *

SPOUSE GENDER *

MALE

FEMALE

SPOUSE SOCIAL SECURITY NUMBER *

SPOUSE DATE OF BIRTH * +

SPOUSE EMPLOYER -Type Self Employed if you work for yourself or are seeking a job. *

SPOUSE MONTHLY INCOME -Expected Income Per Month.

*

Does Your Spouse Need Coverage? *

YES

NO

Do you claim dependents? *

NO

YES

DEPENDENT FIRST NAME *

DEPENDENT LAST NAME *

RELATIONSHIP TO APPLICANT *

DEPENDENT DATE OF BIRTH * +

DEPENDENT SOCIAL SECURITY NUMBER *

DEPENDENT GENDER *

MALE

FEMALE

Does This Dependent Need Coverage? *

yes

no

CITIZENSHIP *

How Do Your Prefer To Be Contacted About This Application? *

PHONE CALL

TEXT MESSAGE

EMAIL

Agreements

Please read the attestations below and indicate your acceptance.

Renewal of coverage

To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt-out at any time.

Tax attestation

I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, Children's Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents:

I must file a federal income tax return for the 2023 tax year.
If I’m married at the end of 2023, I must file a joint income tax return with my spouse.

I also expect that:

No one else will be able to claim me as a dependent on their 2023 federal income tax return.
I’ll claim a personal exemption deduction on my 2023 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.

If any of the above changes:

I understand that it may impact my ability to get the premium tax credit.
I also understand that when I file my 2023 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

Sign and Submit

If anyone on this application enrolls in Medicaid, I’m giving the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I’m also giving the Medicaid agency rights to pursue and get medical support from a spouse or parent.

I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). I know a change in my information could affect eligibility for member(s) of my household.

If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or Children's Health Insurance Program (CHIP)), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.

I acknowledge that the person helping me fill out this form is only a referral source for licensed insurance agents and is NOT a licensed insurance agent and that my information will be forwarded to a licensed insurance agent/ broker licensed in my state and I agree to allow them to contact me to assist me to sign up for health insurance.

ELECTRONIC SIGNATURE - Type your first and last name to sign. *