Simple Health Soluitons

Step 1 of 8

Apply for Health Insurance Online

Do you have Medicare, Medicaid, VA health insurance or does your job offer health insurance?(Required)

Yes

Sorry, we are unable to provide insurance for anyone who already has coverage.

Please email jonathanw.agent@gmail.com to contact a representative.

Since you already have coverage please contact us to discuss the available options.

Apply for Health Insurance

I attest that I qualify for one of the following Special Enrollment Periods

I am losing coverage before the end of the current month

I have lost coverage within the last 60 days

I was denied Medicaid by my state

I recently moved to a new county or state

Other

What is your current doctor's names?

Name(Required)

First Last

Gender(Required)

Male

Female

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County(Required)

Phone(Required)

Email(Required)

Date of birth(Required)

Social Security Number

Social Security number is not required at this time but you must provide it within 3 months or your policy will be terminated.

Employment and Eligibility

Most recent job(Required)

Estimated HOUSEHOLD Income for this year.(Required)

This INCLUDES income from your spouse or child even if they aren’t on the plan. If W2 income before taxes. If 1099 income after deductions.

Hidden

Estimated HOUSEHOLD Income for this year.

This INCLUDES income from your spouse or child even if they aren’t on the plan

How many people need insurance?(Required)

1 (Just You)

3 or more

Taxable household size(Required)

Other than yourself, how many other people are on your tax return? (must file jointly if married to qualify)

Single Member Household

Do you claim anyone else on your taxes?(Required)

I do not claim anyone else

I include other people (spouse, children, etc.)

Please list the name and date of birth of others in your household including those not seeking coverage.

2nd household member

2nd Household Member Name(Required)

First Last

2nd Household Member Date of birth(Required)

2nd persons relationship to 1st person(Required)

Add more household members?

3rd household member

3rd Household Member Name(Required)

First Last

3rd Household Member Date of birth(Required)

3rd persons relationship to 1st person(Required)

4th household member

4th Household Member Name(Required)

First Last

4th Household Member Date of birth(Required)

4th persons relationship to 1st person(Required)

5th household member

5th Household Member Name(Required)

First Last

5th Household Member Date of birth(Required)

5th persons relationship to 1st person(Required)

6th household member

6th Household Member Name(Required)

First Last

6th Household Member Date of birth(Required)

5th persons relationship to 1st person(Required)

Consent for application

I attest that from this day forward Jonathan Webb will be the agent of record for my health insurance plan with the marketplace and will only be replaced by another agent if written notice is submitted to him.

Yes

HealthCare.gov access(Required)

Do you give us permission to access your healthcare.gov account if you have one, in order to enroll you in the best plan possible?

Yes

Free Plan Eligibility(Required)

Do you understand that if you’re not eligible for a free plan we will enroll you in the cheapest plan that is still affordable? (If you decide that you do not want this plan simply don’t pay the bill or call the insurance company to cancel.)

Yes

Signature

Comments

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

Apply for Health Insurance Online

Sorry, we are unable to provide insurance for anyone who already has coverage.

Since you already have coverage please contact us to discuss the available options.

Apply for Health Insurance

Employment and Eligibility

Single Member Household

2nd person needing insurance

3rd person needing insurance

4th person needing insurance

5th person needing insurance

6th person needing insurance

7th person needing insurance

Please list the name and date of birth of others in your household including those not seeking coverage.

2nd household member

3rd household member

4th household member

5th household member

6th household member

Consent for application