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HEALTH APPLICATION

SIGN UP ONLINE

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 for the 2025 tax year.

HEALTH APPLICATION

SIGN UP ONLINE

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 for the 2025 tax year.

HEALTH APPLICATION
If Married, Fill Out Below. If Single, Skip.

SIGN UP ONLINE

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 for the 2025 tax year.

HEALTH APPLICATION

ANY dependents on your tax return need to be on the application

PLEASE UPLOAD LOSS OF COVERAGE LETTER

If you have loss your coverage

SIGN UP ONLINE

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 for the 2025 tax year.

HEALTH APPLICATION
MAIN APPLICANT INFORMATION
ADDRESS INFORMATION
HOUSEHOLD INFORMATION
Do you currently have Medicare, Medicaid, an employer policy or VA benefits? (you will NOT qualify for Obamacare subsidy if you qualify for Medicaid/Medicare/employer or VA plan.

I attest that from this day forward Faith Bratlie NPN 17801407, will be the agent of record for my healthcare.gov insurance plan with the marketplace and will only be replaced by another agent if written notice is submitted to them.

SIGN UP ONILINE

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 for the 2025 tax year.

HEALTH APPLICATION

Socials are only needed if dependent is applying for insurance

SIGN UP ONILINE

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 for the 2025 tax year.

HEALTH APPLICATION
PLAN CHOICE
AGREEMENTS
Please read the attestations below and sign if you agree.
I agree to have my information used and retrieved from government data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from government data sources.
I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage.
Renewal of coverage: To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.
TAX ATTESTATION
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 for the following tax year.
I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit.
I MUST FILE A FEDERAL INCOME RETURN FOR THE FOLLOWING TAX YEAR.
If I’m married at the end of of the year, 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 next federal income tax return. I’ll claim a personal exemption deduction on my next federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.
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 next 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.
I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by texting my agent. I know a change in my information could affect eligibility for member(s) of my household.
PLEASE READ ATTESTATIONS BELOW BEFORE YOU SIGN AND SUBMIT YOUR APPLICATION:
If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.
I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.
Clear

We work with every carrier in the state and will place you in the best option for your situation.

Our goal is to place you in a $0 PREMIUM plan.

CARRIERS WE REPRESENT

THESE ARE ONLY A FEW OF THE CARRIERS WE SHOP TO MAKE SURE YOU HAVE THE PLAN THAT FITS YOUR NEEDS!


We have helped families with their Marketplace application over the last decade. We have created this form to assist you through the enrollment process.

Call us at any time with questions.

(813) 397-8750

We are a licensed Independent Agency operating nationwide to help ensure you get the help you deserve. The average time to complete an online application is 4 minutes. We will then find you the right plan and have you covered with an Insurance carrier from the Affordable Care Act Marketplace if you qualify.

This form is to be used to help you insure you and your family. The information provided must be accurate for the subsidies to be accurate. Submitting this form tells us that to the best of your knowledge all of the above information is accurate.