YOU'RE 1-STEP AWAY FROM SAVING MONEY WITH

YOU'RE 1-STEP AWAY

FROM SAVING MONEY WITH

$0 HEALTH INSURANCE

The Affordable Care Act has served over 40 million Americans

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

Don't Miss Out!

$0 Health Insurance

Don't Miss Out!

$0 Health Insurance

ENTER YOUR DETAILS BELOW TO SEE IF YOU QUALIFY

Zip Code *

Are you currently enrolled into healthcare? *

Yes

No

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 reviewed 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 Personal and 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. 5. Renew my coverage during Open enrollment to prevent lapse in coverage. I confirm that I have reviewed all of the information and it 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 is “long Term”, meaning 365 days and remains in effect un I revoke it by emailing [email protected] or by calling 888-796-9666. By providing my mobile number, I consent to receive SMS communications from Zoom Health and William Burns. I can opt out of texts any time by replying "STOP". I understand that this application is strictly for a subsidy to cover the cost of a qualified health insurance plan in the marketplace. I confirm that I have not been offered or promised anything of monetary value with this application and will not receive cash of gifts of any kind. I understand that the details of the subsidy I am approved for along with the insurance policy will be texted and Emailed to the phone and email that I have provided.

*

Clear

*Full Signature Required to Qualify

I authorize you to be my Agent of Record for long term or 365 days unless I revoke consent. I also authorize you to re-enroll me in the best plan during Open Enrollment if my current plan is not available. *

Clear

*Full Signature Required to Qualify

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YOUR INFORMATION IS 100% SAFE. I UNDERSTAND THAT MY CONSENT IS NOT A CONDITION TO PURCHASE ANYTHING