Just a few questions, and 90% of the people that fill out the form can be signed up without talking to an agent.
How many people need coverage? (2 Screening questions, only 1 more question for FREE health insurance!)
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Are you married or do you claim anyone else on taxes? (last question!)
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Are there only 2 people in the household for your tax return?
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Complete the form to be signed up for FREE health insurance
We’ll sign you up for the best FREE health insurance plan in your area. We work with BCBS, Ambetter, Molina, Brighthealth, Christus and many others. We try to choose plans with the lowest copays and the best coverage available, while keeping your premium at ZERO!
Fields marked with an * are required
Gender *
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Address (to mail your ID cards) *
City *
State *
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ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST
ARMED FORCES AMERICA (EXCEPT CANADA)
ARMED FORCES PACIFIC
Zip *
Phone *
Email to receive enrollment confirmation *
Date of birth *
Most recent job description *
MONTHLY income projected *
Other insurance *
Do you have other insurance through work, VA benefits, Medicare, etc? If you have other insurance, we can't help with this plan
Yes
No
Social Security Number to verify citizenship
If not provided, you will have 90 days to provide your social to the Marketplace. If they do not receive your information within 90 days. The Marketplace will terminate your insurance
We'll send reminders via email, text and phone calls once you've received your ID cards
YES! I give permission to apply for free health insurance!
Robots can't get insurance! What does 2+3= *
Your insurance request has been accepted. We will inform you for further details.
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