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Providing Life, Health &

Retirement Strategies

for Today's

Business Owners & Entrepreneurs  


For a Free Quote Complete the Questionnaire Below 

Please Do Not Skip Any Questions


DISCLOSURE AGREEMENT & CONSENT

MUST READ & AGREE BEFORE APPLYING OR ENROLLING FOR  FINCANCIAL GOVERNMENT ASSISTANCE FROM

HEALTHCARE.GOV/MARKETPLACE 

 

Medicare isn’t part of the Health Insurance Marketplace®, so you don’t need to make any changes. If you have Medicare, you are considered covered.

 

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 in 2024 for the tax year 2024.

• 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 a dependent who is enrolled in coverage through this Marketplace and whose premium for coverage is paid in whole or in part by advance payments. 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.

 

The Federal Government/Marketplace, may request certain documents from me before approving my healthcare coverage/Obamacare. 

 

Please be prepared to show one or more of the following documents:

 

* Letter from Current or Previous Employer/Proof of Healthcare Coverage.

 

* Medicare/Medicaid Denial Letter.

 

* Proof of Income: Check Stub or Self-Employment Ledger, Unemployment Benefits, Pensions, etc.

 

* Proof of Citizenship: Driver's License, State ID, Passport or Birth Certificate, Green Card, or Social Security Card.

 

* Release from Incarceration/Prison Letter.

 

Legal Name *

SEX

Your Current Age?*

Are You a U.S. Citizen?*

Email Address*

Cell*

Complete Mailing Address: Cannot use P.O. Box

Zip *

COUNTY

Do You Currently Have Health Insurance?*

Who's Applying for Coverage*

Are You Married?*

How Old is Your Spouse?

If Married Will You & Spouse File Federal Taxes Together?*

LIST AGE & SEX OF ALL DEPENDENTS YOU WILL CLAIM ON FEDERAL TAXES

What is Your EXPECTED ANNUAL Household Income for 2024? After deductions if you're Self-Employed or 1099 Independent Contractor*

What is Your Source of Income?

What is Your Occupation?

I Want a Quote For

How Did You Hear About Us?

List Additional Info or Message

EMAIL PERMISSION

I HAVE READ & AGREE TO THE HEALTHCARE.GOV DISCLOSURE AGREEMENT & I GIVE MY PERMISSION TO ANDREA WISE TO SERVE AS THE HEALTH INSURANCE AGENT/BROKER.

OBAMACARE OPEN ENROLLMENT 2024 jpg.jpg

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