Marketplace Enrollment Checklist

Personal Information

Name(Required)

Submit your full name the way it appears on your social security card.

First Middle Last

Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Different Mailing Address?(Required)

Is your mailing address different than your physical address?

Yes

Marital Status(Required)

If you are married, you must include your spouse’s income even if he/she does not need coverage. You are also required to file a joint tax return for 2024 when receiving a subsidy.

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Please be sure you can log into your email account or receive emails on your mobile device at the time of your appointment.

Cell Phone(Required)

Home Phone(Required)

Applicant's Date of Birth(Required)

Month

Day

Year

Parish of Residence(Required)

Household Information

Additional Insured

Please list the full name and date of birth for each additional person to be covered by this policy. Use the "+" button to add additional insured.

Full Name

Date of Birth

Relationship to Applicant

Gender

Number of People in Household(Required)

This should be the same number of people you plan to list on your 2024 tax return as your dependent(s).

Total Expected Household Income Expected for 2024(Required)

If your dependents have income, there income MUST be included. (DO NOT include SSI or child support).

Total Expected Applicant Income

List the expected income for each applicant. Use the "+" button to add applicants.

Full Name

Expected Income

Current Providers

Providers

Please list your doctors and hospitals here.

Employer Contact Information

Include current and past employers in 2024.

Employer Name

Phone Number

Marketplace Security Questions

All answeres are case sensitive.

What is your favorite radio station?

What is your favorite food?

List a significant date in your life?

What city was your mother born in?

What was your childhood nickname?

Acknowledgements

Tax Return(Required)

I acknowledge that I MUST file a 2024 tax return and that my Advanced Premium Tax Credit given is based upon the information I provided to the agent. I confirm that all information listed on the application and submitted to the Health Insurance Market Place, is true to the best of my knowledge. I also understand income changes must be immediately reported to healthcare.gov. and that if my income changes, I could owe money back to the Federal government for the advanced premium tax credit/subsidy.

I agree

Spousal Healthcare Coverage (if applicable)

I confirm that health insurance coverage IS NOT offered to me through my job or my spouse’s job if married.

I agree

Current Coverage Offering (if applicable)

I confirm that health insurance coverage IS offered to me and my dependents by my employer/job, but it is unaffordable. Applicant MUST have employer/job complete employer coverage tool form for application to be processed.) Agent can provide the form if needed. )

I agree

Did you recently lose or are losing health insurance coverage?(Required)

Yes

Date you lost (or will lose) coverage(Required)

MM slash DD slash YYYY

Medicare(Required)

I confirm that no one applying for coverage has any Parts of MEDICARE, to include Medicare Part A, Part B, Parts A&B, Part C or Part D.

I agree

Payment(Required)

I confirm that I know that I must make my payment BEFORE my effective date of coverage, or my coverage will be cancelled as if it were never effective by the marketplace. I understand that plan documents will only be sent to me after paying my first premium.

I agree

Married with Tax Credit(Required)

I confirm that if I am married and I receive a Tax Credit, that I MUST file a JOINT 2024 income tax
return with my spouse and must also include their income on the Marketplace application for
coverage even if they do not need/want coverage.

I agree

Do you have an individual or employer group sponsored health reimbursement account?(Required)

Yes

Do you have an individual health reimbursement account (HRA)?(Required)

Yes

Name

This field is for validation purposes and should be left unchanged.

Personal Information

Household Information

Current Providers

Marketplace Security Questions

Acknowledgements

(318) 651-0047