Find Health Insurance Coverage

I give permission to Peace Tree Insurance, Christian Jerome, and their affiliates to access and/or create my application for health insurance on the Federally Facilitated Marketplace (FFM) based on the information I am providing below. *

Yes, I give Permision.

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

Yes No

Main Applicant Date of Birth *

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Social Security Number *

Gender *

Male Female

Marital Status *

Married Single

Spouse

First Name *

Last Name *

Gender *

Male Female

Spouse Date of Birth *

Social Security Number

Will you be claiming any dependents on your taxes in 2024? *

Yes No

Dependent

First Name *

Last Name *

Gender *

Male Female

Dependent Date of Birth *

Social Security Number *

What is your estimated Household Income for 2024? *

$11,000

$36,000

$23,500

$11,000

$18,425

$23,500

$28,747

$36,000

Is that *

Yearly

Which $0 plan carriers are you interested in? *

Best Option (Recommended)
Ambetter
Aetna
Cigna
Molina
UHC
Oscar

* If your plan choice is not available, a licensed agent will choose the best available $0 option for you

Do you use Tobacco Products?

No Yes

Are you on any perscriptions?

What’s your doctors name?

Income Verification

Do you Agree with the Income Verification? *

Yes, I Agree

Consent to Enrollment; Verification of Information

Do you Agree with the Consent? *

Yes, I Agree

Authorization and Tax attestation

Do you Agree with Authorization and Tax attestation? *

Yes, I Agree

Consent Acknowledgement

Do you Agree with Consent Acknowledgement? *

Yes, I Agree

By signing, I grant permission to act on my behalf and that of my entire household in matters related to enrollment in a Qualified Health Plan via the Federally Facilitated Marketplace. This authorization also extends to any authorized representative or power of attorney acting on my behalf. The agents empowered by this agreement are Peace tree Insurance LLC and/or its affiliates. These agents are authorized to locate existing Marketplace applications, complete applications for eligibility in various plans and programs, provide necessary ongoing maintenance, and respond to inquiries about my application from the Marketplace. I understand and agree that my personally identifiable information will be accessed and used solely for the objectives specified in this document. I attest that all the details I provide for the purposes of eligibility and enrollment will be accurate to the best of my ability. I am under no obligation to disclose additional personal or health-related information beyond what is required for these applications. My consent remains effective until I choose to revoke it. For any modifications or to revoke this consent, I can email [email protected] or by calling (877)885-2833.