First Name *

Last Name *

Email *

Phone *

Address *

City *

State *

IP Address

Primary Date of Birth MM/DD/YYYY *

Primary Applicant's Social Security Number *

Do you have a spouse? *

Yes

No

Spouse Legal First Name *

Spouse Legal Last Name *

Spouse's Date of Birth MM/DD/YYYY *

Do you want to enroll your spouse? *

Yes

No

Do you have tax dependants?

Yes

No

Dependent 1 Full Legal Name *

Dependent 1 Date of Birth MM-DD-YYYY *

Do You Have a 2nd Dependent?

Yes

No

Dependent 2 Full Legal Name *

Dependent 2 Date of Birth MM-DD-YYYY *

Do You Have a 3rd Dependent?

Yes

No

Dependent 3 Full Legal Name *

Dependent 3 Date of Birth MM-DD-YYYY *

Do You Have a 4th Dependent?

Yes

No

Dependent 4 Full Legal Name *

Dependent 4 Date of Birth MM-DD-YYYY *

Do You Have a 5th Dependent?

Yes

No

Dependent 5 Full Legal Name *

Dependent 5 Date of Birth MM-DD-YYYY

I agree that I have read this attestation and I give my permission to Zoom Health and William Burns. NPN: 9840086 to serve as my broker for myself and my household, for the purpose of enrollment in a qualified Health Plan offered 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, and by submitting this document I agree that my household income falls within the chart below, that I do not have Medicare/Medicaid/Employer Coverage, and I do not use tobacco products, qualifying myself for Zero Premium Health Coverage. I understand my consent remains until I revoke it by emailing [email protected].

By providing your mobile number, you consent to receive SMS communications from Zoom Health and William Burns. I can opt out of texts any time by replying "STOP"

Authorization Date *

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

Clear

*Full Signature Required to Qualify

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and saved $2.6 billion in the past 9 years

The Affordable Care Act has served over 40 million Americans and saved $2.6 billion in the past 9 years

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Don't Miss Out!

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