IM - ACA Enrollment Form Header Image
Submission Time/Date
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Agent and Product

$
Desired Effective Date

Applicant and Contact Info

Name*
Gender*
Date of Birth*
Home Address*

Background

Are you Re-enrolling for Affordable Care Act coverage?
Are you a US Citizen?*
Are you a naturalized or derived citizen?*
Are you an American Indian or Alaska Native?

Family

Are you Married?*
Do you have any Dependents?

Spouse Infomraiton

Spouse Name*
Spouse Date of Birth*

Dependent 1 Information

Dependent 1 Name*
Dependent 1 Date of Birth
Dependent 1 Gender
Is Dependent 1 on Medicaid?
Does Dependent 1 need coverage?*
Dependents cannot be enrolled without an SSN. If you do not have your dependents SSN please contact our office as soon as you have it available.

Dependent 2 Information

Dependent 2 Name*
Dependent 2 Date of Birth
Dependent 2 Gender
Is Dependent 2 on Medicaid?
Does Dependent 2 need coverage?*
Dependents cannot be enrolled without an SSN. If you do not have your dependents SSN please contact our office as soon as you have it available.

Dependent 3 Information

Dependent 3 Name*
Dependent 3 Date of Birth
Dependent 3 Gender
Is Dependent 3 on Medicaid?
Does Dependent 3 need coverage?*
Dependents cannot be enrolled without an SSN. If you do not have your dependents SSN please contact our office as soon as you have it available.

Dependent 4 Information

Dependent 4 Name*
Dependent 4 Date of Birth
Dependent 4 Gender
Is Dependent 4 on Medicaid?
Does Dependent 4 need coverage?*
Dependents cannot be enrolled without an SSN. If you do not have your dependents SSN please contact our office as soon as you have it available.

Dependent 5 Information

Dependent 5 Name*
Dependent 5 Date of Birth
Dependent 5 Gender
Is Dependent 5 on Medicaid?
Does Dependent 5 need coverage?*
Dependents cannot be enrolled without an SSN. If you do not have your dependents SSN please contact our office as soon as you have it available.

Dependent 6 Information

Dependent 6 Name*
Dependent 6 Date of Birth
Dependent 6 Gender
Is Dependent 6 on Medicaid?
Does Dependent 6 need coverage?*
Dependents cannot be enrolled without an SSN. If you do not have your dependents SSN please contact our office as soon as you have it available.

Family Health and Residence

Do you or a family member smoke or use tobacco products?*
Who smokes or uses tobacco products?
Does everyone live at the same address?
Who lives at a different address?

Income & Employment

Did you file taxes last year?
Will you file taxes this year?
Will you file your taxes jointly with your spouse?
Are you a fulltime student?
Have you received Unemployment Benefits since 1/1/2022*

Important Note about Accurately Stating your Expected Income

Your total household taxable income is used to determine your eligibility for the Affordable Care Act subsidy. Incorrect information can cause loss of ACA subsidy, making the policy holder responsible for reimbursing the federal government the total subsidized amount at the end of the year. If you are unemployed, self-employed, on commission, or on a work schedule that changes regularly your income is hard to predict. Base your estimate on your past experience, recent trends, what you know about possible changes at your workplace and similar information. If the job is new to you, it is recommended that you consult people in the same field or in the same company about their experiences.

Are you currently employed?*
$
$
Is your spouse currently employed?*
$
$
$
$
If the calculated value above is inaccurate for any reason please update the value appropratlye
The amounts entered above are an accurate estimate of my total household income based on my knowledge on the date of this application.*

Notes and Documentation

ID Type
No File Chosen
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I am interested in the following additional coverage*
Best Time to Contact
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Agreements

Marketplace savings are based on your expected household income for the year you want coverage, not last year’s income. Income is counted for you, your spouse, and everyone you'll claim as a tax dependent on your federal tax return (if the dependents are required to file). Include their income even if they don’t need health coverage.

I understand the above statement*

Disclosure Agreement: By signing this document, I authorize Insurance Masters, a licensed Insurance Agent/Agency and its affiliates, employees and agents, to use the confidential information on this document only for the purposes of determining eligibility for healthcare coverage subsidy, enrollment in healthcare, and/or related government assistance or other insurance programs, granting permission to access your healthcare.gov application and in making an application for healthcare coverage and updating said application as needed to keep coverage active as long as possible until instructed otherwise. 

No application for ANY product will be submitted on my behalf until I have chosen it and have given consent to purchase. I give my permission for the above-mentioned entities/persons to contact me for the purposes of further determining eligibility, educating me on health and other insurance options, and/or setting an appointment or means to review and/or sign an application for insurance. I will make Insurance Masters aware of any changes to my qualifying information and will accept all responsibility for failure to keep information current and/or submitting requested proof from the Health Insurance Marketplace.

By clicking the submit button, I agree to terms & conditions*
Signatory's Name*
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Date/Time
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