As a friend Of
's Network, You Could Qualify For Free Health Care.

Sign up today to see if you qualify for free healthcare coverage.

Start saving today!

✔️ $0 monthly premiums.

✔️ $0 deductible.

✔️ $0 doctor copays.

✔️ No hassle sign up!

✔️ Zero deductible plan available now!

✔️ High-quality plans from top providers!

Fill in your details below to apply for free health insurance.

Answer the Following Questions Accurately to Authorize Your Application!

Primary First Name *

Primary Last Name *

Primary Cell Phone (Can never have been used for this survey before). *

Primary Email (Can never have been used for this survey before). *

Primary Date of Birth MM-DD-YYYY *

Primary Gender *

Primary Applicant's Social Security Number *

Do You Have A Spouse To Enroll? *

Spouse Legal First Name *

Spouse Legal Last Name *

Date of Birth MM-DD-YYYY *

Spouse Gender *

Spouse's Social Security Number *

Do You Have A Dependent To Enroll? *

Dependent 1 Full Legal Name *

Dependent 1 Gender *

Date of Birth MM-DD-YYYY *

Dependent 1 Social Security Number *

Do You Have A Second Dependent To Enroll? *

Dependent 2 Full Legal Name *

Dependent 2 Gender *

Date of Birth MM-DD-YYYY *

Dependent 2 Social Security Number *

Do You Have A Third Dependent To Enroll? *

Dependent 3 Full Legal Name *

Dependent 3 Gender *

Date of Birth MM-DD-YYYY *

Dependent 3 Social Security Number *

Do You Have A Fourth Dependent To Enroll? *

Dependent 4 Full Legal Name *

Dependent 4 Gender *

Date of Birth MM-DD-YYYY *

Dependent 4 Social Security Number *

Do You Have A Fifth Dependent To Enroll? *

Dependent 5 Full Legal Name *

Dependent 5 Gender *

Date of Birth MM-DD-YYYY *

Dependent 5 Social Security Number *

Do You Have A Sixth Dependent To Enroll? *

Dependent 6 Full Legal Name *

Dependent 6 Gender *

Dependent 6 Date of Birth MM-DD-YYYY *

Dependent 6 Social Security Number *

Address *

City *

State *

Postal code *

I give my permission to the agent 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 to use the information provided by me in writing, electronically, or by telephone for the following purposes:

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 Marketplace premiums; Providing ongoing account maintenance and enrollment assistance, as necessary; or Responding to inquiries from the Marketplace regarding my Marketplace application for the next 60 months.

Name of Primary Writing Agent: Megan Matteson

Phone Number: (949) 353-6977

Email Address: [email protected]

Agent NPN: 20702935

SMS (Text Message) Consent:

By providing your mobile number, you consent to receive

SMS (text message) communications from Megan Matteson.

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. Also that your income falls in the following chart, qualifying you for the Zero Premium Health Coverage.

*not all applicants qualify for the subsidies and/or $500 Rewards.

Upon signing & 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.

Authorization Date *

Authorization Signature *

Clear

Powered By Referralsite.com

As a friend Of 's Network, You Could Qualify For Free Health Care.

Sign up today to see if you qualify for free healthcare coverage.

Start saving today!

Fill in your details below to apply for free health insurance.

Powered By Referralsite.com

Grow your business with referrals

As a friend Of
's Network, You Could Qualify For Free Health Care.