(904) 717-1176

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bill@greeninsagency.com

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THE EASY 5 MINUTE HEALTH INSURANCE APPLICATION

We have helped families with their Marketplace application since 2014. We have created this form to assist you through the enrollment process.

You can call us at any time at (904) 717-1176

SIGN UP ONLINE

You are one step from new coverage. We work with every carrier in the state and will place you in the best option in your situation. Our goal is to place you in a $0 PREMIUM plan. Please answer the questions below:

How many people need coverage? *

- select an option -

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No elements found. Consider changing the search query.
List is empty.

Are you married?

Yes

No

Yes I'm Married:

Spouse Name

Does Spouse Need Coverage?

Yes

No

Spouse Social Security Number (no dashes)

Socials are not required to get insurance BUT you will need to provide it within 90 days

Name of Employer for Spouse

Spouse Expected Income Per Month

$

Do you want to apply for a subsidy to pay for your insurance?

Yes

No

MAIN APPLICANT INFORMATION

Full Name

Date of Birth

Cell Phone Number

Email

ADDRESS INFORMATION

Address

City

State

Postal code

HOUSEHOLD INFORMATION

Socials are not required to get insurance BUT you will need to provide it within 90 days

Name of Your Employer

Expected Income Per Month

$

Do You Claim Any Dependents?

- select -

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No elements found. Consider changing the search query.
List is empty.

Please Add Info for Dependent #1

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 2nd Dependent?

Yes

No

Please Add Info for Dependent #2

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 3rd Dependent?

Yes

No

Please Add Info for Dependent #3

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 4th Dependent?

Yes

No

Please Add Info for Dependent #4

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 5th Dependent?

Yes

No

Please Add Info for Dependent #5

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 6th Dependent?

Yes

No

Please Add Info for Dependent #6

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 7th Dependent?

Yes

No

Please Add Info for Dependent #7

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 8th Dependent?

Yes

No

Please Add Info for Dependent #8

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 9th Dependent?

Yes

No

Please Add Info for Dependent #9

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Do you authorize Green Insurance Agency to place you in an insurance plan?

Yes

No

Do you give Green Insurance Agency authorization to access your Marketplace Account and make changes if needed?

Yes

No

Do you have insurance through your employer, Medicare or VA?

Yes

No

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We have helped families with their Marketplace application since 2014. We have created this form to assist you through the enrollment process.

We will never call you. Only a text or email if there is an issue with your new health insurance.

You can call us at any time

Click Here To Call

This form is to be used to help you insure you and your family. The information provided must be accurate for the subsidies to be accurate. Our job is impossible with incorrect information. Submitting this form tells us that to the best of your knowledge all of the above information is accurate. You will not receive any phone calls from Green Insurance Agency. We will however text or email you if the Marketplace requests anything from you. You will also receive everything in the mail. Let us know if you need any further assistance.