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Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
1. CURRENT COVERAGE (Please check all that apply)
I have health insurance.
I don't have a health insurance plan.
I lost Medicaid sometime this year.
I lost job coverage this year.
I moved sometime this year.
What health insurance carrier are you a customer of?
When did you lose Medicare/Medicaid?
-
Month
-
Day
Year
Date
When did you lose job coverage?
-
Month
-
Day
Year
Date
When did you move and what was your previous zip code?
2. I WANT COVERAGE
Mostly for general health checkups/meds
Because I have a chronic disease
There is a procedure or operation I need to have
3. HOUSEHOLD INFORMATION: Please list out the names and dates of birth of all household members that will appear in your tax return. Include SS# for all those that need insurance coverage.
Full Name
Date of Birth (MM-DD-YYYY)
Social Security #
Relationship
1
2
3
4
5
6
7
8
If your income is in the blue range, you qualify for a $0 or low-cost health plan with subsidies!
4. What will the estimated gross income of your entire household be for the current year?
What is your employer's name? Please note if you're self-employed.
Do you pay student loans or alimony? Please note that sharing information about this will allow us to reduce your premiums and get you the cheapest possible health insurance plan!
Yes
No
How much do you pay monthly for student loans/alimony?
5. We strive to provide $0 premium plans or the lowest possible cost. If a 0$ plan is not available in your area, what is your monthly budget for your health plan?
If we are able to find a policy within your budget, do we have your permission to contact you about it?
Yes
No
I give my permission to Duckrow Financial Services LLC to serve as the health insurance agent or broker for myself and my entire household, if applicable, for purposes of enrollment in a QualifiedHealth Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize Duckrow Financial Services LLC to view and use the confidential information provided by me in writing, electronically, orby telephone only for the purposes of: Searching for an existing Marketplace application; 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 Market place premiums; Providing on going account maintenance and enrollment assistance, as necessary; or responding to inquiries from the Marketplace regarding my Marketplace application. I understand that Duckrow Financial Services LLC will not use or share my personally identifiable information (PII) for any purposes other than those listed above. Duckrow Financial Services LLC will ensure that my PIIis kept private and safe when collecting, storing, and using my PII for the stated purposes above. Income Attestation: I confirm that the information I've provided regarding my income is true and accurate. I further attest that I will be making the minimum required income to qualify for subsidized healthcare under the Federally Facilitated Marketplace. I understand that this information will be used to determine my eligibility for health insurance programs and potential subsidies. Scope ofAppointment: I appoint Duckrow Financial Services LLC as my authorized representative and Agent of Record for the purposes of: Searching for and completing applications on the Marketplace. Handling renewals and making necessary changes to my health insurance plan.Providing ongoing account maintenance and enrollment assistance. Responding to inquiries from the Marketplace regarding my application. By this agreement, I designate Duckrow Financial Services LLC to represent and assist me in all interactions with the health insurance provider for a duration of up to 3 years. By signing below, you acknowledge the following:You agree to the terms and conditions outlined in this attestation. You respectfully request Duckrow Financial Services LLC's expertise to enroll you and/or your family in the most suitable zero premiumACA plan available. In the event that no zero premium health plan is available in your area, you understand that we will disclose the available plans and seek your consent before proceeding with enrollment. You authorize Duckrow Financial Services LLC to access yourhealthcare.gov account and submit the necessary information as required to Duckrow Financial Services LLC NPN 71326693 Signature
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If there is any additional information or comments please feel free to let us know below.
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