Get $0 ACA/Health Coverage Without To Speaking To An Agent Or Filling Out Any Confusing Forms

Receive A Complimentary 4 Day 3 Night Vacation Voucher

Take about 3 Minutes To Answer

Some Basic Questions

Are you currently on Medicaid or Medicare? *

Yes

No

Confirm Your Medicaid/Medicare Answer *

Yes, I have Medicare or Medicaid

No, that was a mistake.

Your Employment Information *

Employed

Unemployed

Receiving Social Security

Employer Name

2022 Annual Income

Projected Income 2023

Your Monthly Social Security Income

Marital Status *

Single

Married

Divorced

Widowed

Spouse's Name

Spouse's DOB

Spouse's Employment

Employed

Unemployed

Social Security Benefits

Spouse Employer Name

Spouse's 2023 Estimated Annual Income If Any

Spouse's Social Security# ?

Do You Want Your Spouse Covered On This Policy? *

Yes

No

Do you want Children Covered on The Policy *

Yes

No

Child's Full Name

Child's DOB

Child's SSN

If you have another child, please add their details below

2nd Child Name

2nd Child DOB

2nd Child Social Security Number

Do you have a primary doctor you see regularly *

Yes

No

Doctors Full Name

Doctors City

Were you found NOT eligible for Medicaid AND applied for coverage between 11/1/22-1/15/23? (This will create a Special Enrollment Period/possibly $0 Health Premium)

Not Eligible for Medicaid *

Yes, I was found not eligible for Medicaid or CHIP in the last 60 days AND applied for coverage between 11/1/22-1/15/23

No

Do you use Tobacco products? *

Yes

No

Almost Done! Let's Get Your Info

First Name *

Last Name *

Date of birth *

Phone *

Email *

City *

State *

Postal code *

Address *

An 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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