Enter Your Information To Qualify For Your $0 Health Plan

Legal First Name *

Legal Last Name *

Date of birth

What Is Your Birth Gender *

Male

Female

Phone *

Email *

Address *

City *

State *

Postal code *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Spouse Legal Name *

Spouse Date of Birth *

Has your spouse used tobacco 4 or more times a week for the past 6 months? *

Yes

No

Spouse Employment *

Employed

Self-Employed

Receiving Social Security Benefits

Seeking Employment

Spouse 2024 Estimated Monthly Income *

Do you want your spouse covered on this plan? *

Yes

No

Spouse Social Security Number

Your Employment Information *

Employed

Seeking Employment

Receiving Social Security

Employer Name

Employer Phone Number

2024 Expected Monthly Income (Must Be $2500 Or Under Per House Individual) *

SSI Monthly Income *

Do you believe you will be making more than $16,000 - $21,000 a year? *

Yes

No

Are you claiming any dependents on your taxes for 2024? *

Yes

No

Child Full Legal Name *

Child Date of Birth *

Child Social

Additional Dependents Info (only enter social if you want them covered)

Current Doctor's Full Name

Doctor's City

In order to receive a healthcare subsidy and assistance also known as an Advanced Premium Tax Credit (APTC) or Cost Reduction Sharing, you are must file taxes for the upcoming year, even if your income is not taxable. Will you file taxes next year?

Yes

No

The federal marketplace keeps track of those requiring assistance. For this to work, individuals must file taxes every year, even if their income is not taxable or their income is below the poverty line. You MUST file taxes even if you don't owe anything. Will you file taxes next year?

Yes

No

What Is Your Social Security Number? *

Consent To Search *

1) By Clicking this box I attest that all of the information entered is true and correct to the best of my knowledge. I also give my permission to Monarch Agency Solutions, National License #s Jennifer Cuartas, 18126839 and its agents to represent me and my household (if applicable), as my healthcare agent/broker and to process my application with the information provided. This includes searching any existing and/or duplicate plans, relaying and updating documents requested by CMS on my behalf, and protecting and keeping my personal identifying information (PII) safe and secure. I understand I may revoke or modify this permission at any time by contacting my agents at Monarch Agency SolutionsLLC has the authority to search for and add existing Healthcare.gov customers to our Account.

Signature *

Clear

Consent To Enroll *

Terms Of Consent & Enrollment I Give my permission to Monarch Agency Solutions 1. Search for an existing Marketplace application 2. Completing an application for eligibility and enrollment in a marketplace Qualified Health Plan or government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace Premiums or enrollment in off-exchange insurance products as applicable. 3. Providing ongoing account maintenance and enrollment assistance, as necessary; or 4. Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that Monarch Agency SolutionsLLC and/or their staff will NOT share my personally identifiable information (PII), and they will ensure that my PII is kept private and safe when collecting, storing, and using my information for the state purposes above. I confirm that the information I provide for entry on my marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my coverage at any time. I understand that requests must be made in writing. By submitting my information I attest that all of the information entered is true and correct to the best of my knowledge. I also give my permission to Monarch Agency Solutions, , National License #s Jennifer Cuartas, 18126839, and its agents to represent me and my household (if applicable), as my healthcare agent/broker and to process my application with the information provided. This includes searching any existing and/or duplicate plans, relaying and updating documents requested by CMS on my behalf, and protecting and keeping my personal identifying information (PII) safe and secure. I understand I may revoke or modify this permission at any time by contacting my agent, Jennifer Cuartas, at any time. ACA Disclosures 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. 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 2024 tax year. • If I’m married at the end of 2024, 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 2024 federal income tax return. • I’ll claim a personal exemption deduction on my 2024 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 2024 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. 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 the 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. I understand that in order to revoke consent from Monarch Agency Solutions to represent me within the marketplace as my agent of record I must give Monarch Agency Solutions 30 days written notice of the fact. If anyone on your application is enrolled in Marketplace coverage and is also found to have Medicare coverage, the Marketplace will automatically end their Marketplace plan coverage. They will get a notice before Marketplace terminates their coverage in case they need to keep it or make changes. During all the months of overlapping coverage, they're responsible for paying the full cost for the Marketplace plan premium and covered services. 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. Consent & Enrollment I Give my permission to Monarch Agency Solutions 1. Search for an existing Marketplace application 2. Completing an application for eligibility and enrollment in a marketplace Qualified Health Plan or government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace Premiums or enrollment in off-exchange insurance products as applicable. 3. Providing ongoing account maintenance and enrollment assistance, as necessary; or 4. Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that Monarch Agency Solutions and/or their staff will NOT share my personally identifiable information (PII), and they will ensure that my PII is kept private and safe when collecting, storing, and using my information for the state purposes above. I confirm that the information I provide for entry on my marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my coverage at any time. I understand that requests must be made in writing, either by sending the request via email to [email protected]. By submitting my information I attest that all of the information entered is true and correct to the best of my knowledge. I also give my permission to Monarch Agency SolutionsLLC, National License #s Jennifer Cuartas, 18126839, and its agents to represent me and my household (if applicable), as my healthcare agent/broker and to process my application with the information provided. This includes searching any existing and/or duplicate plans, relaying and updating documents requested by CMS on my behalf, and protecting and keeping my personal identifying information (PII) safe and secure. I understand I may revoke or modify this permission at any time by contacting my agents at any time. ACA Disclosures 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. 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 2024 tax year. • If I’m married at the end of 2024, 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 2024 federal income tax return. • I’ll claim a personal exemption deduction on my 2024 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 2024 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. 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 the 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. I understand that in order to revoke consent from Monarch Agency Solutions to represent me within the marketplace as my agent of record I must give Monarch Agency Solutions 30 days written notice of the fact. If anyone on your application is enrolled in Marketplace coverage and is also found to have Medicare coverage, the Marketplace will automatically end their Marketplace plan coverage. They will get a notice before Marketplace terminates their coverage in case they need to keep it or make changes. During all the months of overlapping coverage, they're responsible for paying the full cost for the Marketplace plan premium and covered services. 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.

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By Submitting this form I attest that all of the information entered is true and correct to the best of my knowledge. I also give my permission to
Licensed Insurance Advisors LLC, National License #16004323 and 17356930, and it's agents to represent me and my household (if applicable), as my healthcare agent/broker and to process my application with the information provided. This includes searching any existing and/or duplicate plans, relaying and updating documents requested by CMS on my behalf, and protecting and keeping my personal identifying information (PII) safe and secure. I understand I may revoke or modify this permission at any time by contacting my agent, at any time.

riskadvisors.fast-term-life.com is privately owned and operated by . Invitations for applications for insurance on
Licensed Insurance Advisors LLC are made throughwww.aiomarketinglba.com, LLC. NPN #: National License #16004323 and 17356930, or through its designated agent,
Licensed Insurance Advisors LLC, only where licensed and appointed. Health Enrollment licensing information can be found here. Submission of your information constitutes permission for an agent to contact you with additional information about the cost and coverage details of health plans. Possible options include, but are not limited to Major Medical Plans, Short Term Plans, Fixed Indemnity Plans, and more. Descriptions are for informational purposes only and subject to change. Insurance plans may not be available in all states. For a complete description, please call us to determine eligibility and to request a copy of the applicable policy.

Licensed Insurance Advisors LLC has been verified as an approved Health Insurance Provider qualified to offer ACA / Marketplace Plans. A list of our licenses can be found here.

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