What is your address where we can mail the cards?

Street Address *

City *

State *

Postal code *

Primary Applicant's Date of Birth MM-DD-YYYY *

Primary Applicant's Social Security Number *

Annual Net Household Income *

$

Do You Have A Spouse? *

Yes

No

Spouse Legal First Name *

Spouse Legal Last Name *

Spouse's Gender *

Male

Female

Spouse's Date of Birth MM-DD-YYYY *

Spouse's Social Security Number *

Do You Have Any Dependents to Enroll? *

Yes

No

Dependent 1 Full Legal Name *

Dependent 1 Gender *

Dependent 1 Date of Birth MM-DD-YYYY *

To help qualify you and your family for this premium tax credit, the application asks for the Social Security Numbers of your Dependents. Please be advised that if you prefer not to add the number to this form, your health agent will be reaching out for the information prior to submitting the application.

Dependent 1 SSN *

Do You Have a 2nd Dependent? *

Yes

No

Dependent 2 Full Legal Name *

Dependent 2 Gender *

Dependent 2 Date of Birth MM-DD-YYYY *

Dependent 2 SSN *

Do You Have a 3rd Dependent? *

Yes

No

Dependent 3 Full Legal Name *

Dependent 3 Gender *

Dependent 3 Date of Birth MM-DD-YYYY *

Dependent 3 SSN *

Do You Have A 4th Dependent To Enroll?

Yes

No

Dependent 4 Full Legal Name *

Dependent 4 Gender *

Dependent 4 Date of Birth MM-DD-YYYY *

Dependent 4 SSN *

Do You Have A 5th Dependent? *

Yes

No

Dependent 5 Full Legal Name *

Dependent 5 Gender *

Dependent 5 Date of Birth MM-DD-YYYY *

Dependent 5 SSN *

1. Search for an existing Marketplace Plan; 2. Complete an application for eligibility and enrollment in a Marketplace Plan; 3. Provide ongoing maintenance and enrollment assistance; or 4. Respond to inquiries from the Marketplace regarding my application.

Authorization Date *

Authorization Signature - I authorize Armando Torres and/or an agent of Powerhouse Health to be my Agent of Record each month until I revoke consent and re-enroll me in the best plan during Open Enrollment if my current plan is discontinued. *

Clear

We have a range of options available, and qualifying for health insurance can be simpler than you might think.