Answer the Following Questions Accurately to Authorize Your Application!

Your First Name *

Your Last Name *

Your Email *

Your Phone *

Your Social Security Number (SSN)

Confirm Income *

Your Gender *

Do You Have A Spouse To Enroll? *

Spouse Legal First Name *

Spouse Legal Last Name *

Spouse Date of Birth *

Spouse Gender *

Spouse's Social Security Number

Do You Have A Dependent To Enroll? *

Dependent 1 First Legal Name *

Dependent 1 Last Legal Name *

Dependent 1 Gender *

Dependent 1 Date of Birth *

Dependent 1 Social Security Number

Do You Have A Second Dependent To Enroll? *

Dependent 2 First Legal Name *

Dependent 2 Last Legal Name *

Dependent 2 Gender *

Dependent 2 Date of Birth

Dependent 2 Social Security Number

Today's Date *

I give my permission to the agent/agency listed below, or one of the designated agents listed below**, to serve as the health insurance agent or broker for myself and my entire household for purposes of enrollment in a Qualified Marketplace Health Plan. By consenting to this agreement, I also authorize said Agent, or his licensed designee to use the information provided by me in writing, electronically, or by telephone for the following purposes:

Your Agent/Agency: Kevin Mehler
Phone Number: (888) 255-3370
Email Address: info@yourseniorbenefitssolutions.com
Agent NPN: 18756431

SMS (Text Message) Consent:
By providing your mobile number, you consent to receive
SMS (text message) communications from Britt Parent.

**Designated Agents:

Upon submitting this document I am confirming I DO NOT currently have Medicare, Medicaid, Group, federally recognized Tribes, or ANCSA shareholder Insurance Coverage.

By consenting to this agreement, I also authorize said Agent to use the information provided by me in writing, electronically, or by telephone for the following purposes:

I authorize the agent listed to search 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 Marketplace premiums. Providing ongoing account maintenance and enrollment assistance, as necessary. Responding to inquiries from the Marketplace regarding my Marketplace application for the next 60 months.

I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my agent at the email address or phone number provided below.

Msg & data rates may apply. You can opt out at any time by replying 'STOP'. By submitting this document, you agree the above information is true and accurate. Please note, not all applicants qualify for the subsidies and/or $500 Rewards. However, our insurance plans offer a range of benefits that could be advantageous for you. Upon submitting this document, I am confirming I DO NOT currently have Medicare, Medicaid, Group, federally recognized Tribes, or ANCSA shareholder Insurance Coverage. We cannot take any actions that jeopardize these types of coverage.