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Marketplace Enrollment Checklist
Marketplace Enrollment Checklist
squareplanit
2023-11-20T07:30:41-06:00
Step
1
of
5
20%
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Different Mailing Address?
(Required)
Is your mailing address different than your physical address?
Yes
No
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.
Single
Married
Divorced
Widowed
Mailing Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Add
Remove
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
Add
Remove
Current Providers
Providers
Please list your doctors and hospitals here.
Employer Contact Information
Include current and past employers in 2024.
Employer Name
Phone Number
Add
Remove
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
No
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
No
Do you have an individual health reimbursement account (HRA)?
(Required)
Yes
No
Name
This field is for validation purposes and should be left unchanged.
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