ACA $0 Health Insurance Application

ACA Health Insurance Application

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Who Referred You? *
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This is the person helping you complete this application.
Name *
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Please Upload a Copy of ___'s Government Issued ID

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Upload file Capture image using webcam
Is ___ ___ the name listed on your Social Security Card?
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Yes
No
What is the name listed on your Social Security Card?
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Click here if ___ doesn't have a permanent address
Yes No
Click here if ___ doesn't have a permanent address
Address *
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Phone *
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### ### ####

A VALID phone number that belongs to the primary insured.
Email
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Social Security Number *
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Date of Birth *
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MM/dd/yyyy
Gender *
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Tobacco User Yes No Tobacco User

Check this box if you have used tobacco four or more times a week in the past six months.
Estimated Monthly Income USD *
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The minimum income to qualify is $1,200 per month.
Annual Income
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I understand that this application is being submitted to the marketplace to obtain new health insurance coverage. * Understood I understand that this application is being submitted to the marketplace to obtain new health insurance coverage. Required
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I confirm I am not currently enrolled in Medicare, Medicaid, VA benefits, Employer, or Marketplace coverage. * Confirmed I confirm I am not currently enrolled in Medicare, Medicaid, VA benefits, Employer, or Marketplace coverage. Required
Tax Filing Status *
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Spouse and Dependent Details
-- No Fields Available --
- Name
- Relationship to Applicant
- Gender
- Date of Birth
- Social Security Number
- Tobacco User
- Insure this person?
Add Dependent Add Dependent
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- Name
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  Required First Name Required Last Name
- Relationship to Applicant *
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- Gender *
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- Date of Birth *
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  MM/dd/yyyy
- Social Security Number *
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  Tobacco User Tobacco User Tobacco User
- Insure this person? *
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- #1
- Name
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  Required First Name Required Last Name
- Relationship to Applicant *
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- Gender *
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- Date of Birth *
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  MM/dd/yyyy
- Social Security Number *
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  Tobacco User Tobacco User Tobacco User
- Insure this person? *
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You are required to list all individuals listed on your tax return in order to qualify for the subsidy that pays for your health insurance plan.
Citizenship *
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Please upload one of the following
- Permanent Resident Card, "Green Card" (I-551)
- Reentry Permit (I-327)
- Refugee Travel Document (I-571)
- Employment Authorization Card (I-766)
- Machine Readable Immigrant Visa (with temporary I-551 language)
- Temporary I-551 Stamp (on Passport or I-94/I-94A)
- Foreign passport
- Arrival/Departure Record (I-94/I-94A)
- Arrival/Departure Record in foreign passport (I-94)
- Certificate of Eligibility for Nonimmigrant Student Status (I-20)
- Certificate of Eligibility for Exchange Visitor Status (DS-2019)
- Notice of Action (I-797)
- Document indicating a member of a federally recognized Indian tribe or American Indian born in Canada
- Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee Resettlement (ORR)
- Document indicating withholding of removal (or withholding of deportation)
- Office of Refugee Resettlement (ORR) eligibility letter (if under 18)
- Resident of American Samoa Card
Upload Proof of Legal Presence *
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Upload file Capture image using webcam
How Do you Prefer to Be Contacted About This Application? *
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Signature *
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Type your full name above to sign electronically.
Consent *
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I, ___ ___, give my permission to Jesse Smedley, NPN 9655617 to serve as the health insurance broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the State or Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Broker and his office staff to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:
1. Searching for an existing Marketplace application;
1. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums;
1. Providing ongoing account maintenance and enrollment assistance, as necessary; or
1. Responding to inquiries from the Marketplace regarding my Marketplace application.
I understand that the Broker will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Broker will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Broker beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by phone or email.

Name of Primary Writing Broker: Jesse Smedley
Broker National Producer Number: 9655617
Name of Agency: Smedley Insurance Group, Inc. DBA: iHealthBrokers
Agency National Producer Number: 11171590
Phone Number: (866) 260-9829
Email Address: support@iHealthBrokers.com

I understand that failure to adhere to all of the information below may result in loss or repayment of any or all tax credits to the IRS. By completing and signing this form I am confirming receipt and understanding of all of the following:
1. I understand the 2024 Adjusted Gross and household information I provided qualifies me for Premium Tax Credits.
1. I am aware that I must file my 2024 taxes and reconcile my premium tax credit. 1095A forms will be mailed to members in January 2024.
1. I have provided information for all dependents and understand that if I am legally married I am required to file taxes jointly.
1. I understand that if I qualify for health insurance through my employer, a spouse’s employer, a parent’s employer, Medicaid, TRICARE, VA Coverage, etc., I may not be eligible for the premium tax credit. To be eligible for the premium tax credit my share of the monthly premium in the lowest-cost plan offered to me must be higher than 9.12% of your household income.
1. I understand I may be denied coverage if I did not disclose the use of tobacco products more than 4 times a week in the past 6 months in any form (cigarettes, cigars, oral tobacco, pipe, etc.), during the application process.
I accept the Terms and Conditions.
Lead Source
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ACA Health Insurance Application

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