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First Name *

Last Name *

Birthday *

Cell Phone *

Email Address *

Residential Address *

City *

State *

Zip *

Mailing address the same?

Yes

No

What is your Mailing Address? *

Select YES if you've used tobacco 4 or more times a week for the past 6 months. You may pay more for insurance, but if you get a related illness and do not report you are tobacco user, your insurance can deny you coverage.

Do you use Tobacco? *

Yes

No

What is your Gender? *

Male

Female

Are you pregnant or plan on becoming pregnant? *

Yes

No

What is your Marital Status *

Please complete information even if your spouse does not need coverage

Does your Spouse need covered on this policy? *

Yes

No

Spouse's Name *

Spouse's DOB *

Spouse's SSN *

Spouse's Employment *

Employed

Umemployed

Social Security Benefits

Spouse's 2022 Estimated Annual Income *If Any

$

Will you be filing taxes jointly with your spouse for 2023? *

Yes

No

Personal Employment 2022 *

Employed

Unemployed

Receiving Social Security

Employer Name *

Estimated 2023 Annual Income *

$

Does your employer offer you insurance? *

Yes

No

SS Income Amount *

$

How often do you get this amount? *

Do you currently have Medicare? *

Yes

No

What is your estimated total annual income for 2023?

$

$0 - I estimate my annual income for 2023 to be $0

If making less than $1100/mo, I agree I am looking for a job making minimum wage or better

Will you claim any dependents on your taxes? *

Yes

No

Please provide this information even if your dependents do not need coverage

Dependent 1 *

Full Name
Date of Birth
SSN
Gender

Dependent 1 Coverage *

Yes, add this this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 2 *

Full Name
Date of Birth
SSN
Gender

Dependent 2 Coverage *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 3 *

Full Name
Date of Birth
SSN
Gender

Dependent 3 Coverage *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 4 *

Full Name
Date of Birth
SSN
Gender

Dependent 4 Coverage *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 5 *

Full Name
Date of Birth
SSN
Gender

Dependent 5 Coverage *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 6 *

Full Name
Date of Birth
SSN
Gender

Dependent 6 Coverage *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent Names & Gender (press enter after each gender) *

Dependent Birthdays (press enter after each DOB) *

Dependent SSNs (press enter after each SSN) *

Do all of these dependents need covered on this policy? *

Yes

No

Do you have currently have Health Insurance? *

Yes

No

What kind of insurance do you have? *

Medicare Card Number *

Part A Effective Date *

Part B Effective Date *

Do you have a Primary Care Doctor you see regularly? *

Yes

No

Primary Care Doctor's Full Name *

What city are they in? *

Do have any specialist you see? *

Yes

No

Please list all Specialist Names and Cities (press enter to after each for multiple) *

Do you take any prescription medicine? *

Yes

No

Please list all prescription medicine you take: *

Preferred Pharmacy

Your Social Security Number *

Confirmation *

By checking this box, you attest that all of the information is true and correct to the best of your knowledge. You are giving Your Health Pros the permission to finish processing your Health Insurance Marketplace application for the duration of one (1) calendar year from the date of signature. You also agree to Your Health Pros becoming your Agent of Record with your health insurance provider through the Health Insurance Marketplace.

Signature *

Clear

Your Source for Information

Our team of experts review all plan options and suggest only the best sense for your needs and your budget.

Access to All Your Options

Our team of experts review all plan options and suggest only the best sense for your needs and your budget.

Personal Medicare Agents

Our phones are always open to take any questions or concerns you might have during your coverage period.

We Simplify the Enrollment Process

We offer innovative approaches to improving quality, affordability, and accessibility to healthcare information. At Your Health Pros, we believe mapping a path into a new life stage should be free of confusion and doubt, so we are here to guide you through the process to feel confident and make the right health insurance decisions.