healthcare.gov

Application Type *

Agent currently assisting me *

Please begin entering your information below this line.

Personal Information:

* Indicates required field

Your Name *

First

Last

Your Date of Birth *

Physical address *

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Line 2

City

State

Zip Code

Country

P.O. BOX or Alternate Address *

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Line 2

City

State

Zip Code

Country

Email *

Phone Number *

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OPTIONAL SECTION:
Fill out this section if you're, married living together and (or) filing with said spouse.

Spouse's name *

First

Last

Spouse's Date of Birth *

Spouse's annual income (only if filing joint together) *

Souse's social security number (If your spouse needs coverage as well) *

What's your spouse monthly income *

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What's your race (optional) *

Medicare number if applicable ............ - 1EG4-TE5-MK72 *

Medicaid # *

Do you have heart failure, diabetes, or cardiovascular disorder. *

- Heart Failure - Diabetes - Cardiovascular disorder - Neither

Does anybody applying for coverage have Disabilities that affect your ability to work or attend school. *

Does anybody applying for coverage need help with bathing, dressing, or using the restroom *

List each medication in the box: Types of medicine/ how long have you been on this prescription/ how many milligrams *

Who is your primary care doctor? *

To determine if you're eligible for savings, we need to ask about your income. Click to view a list of acceptable types.

Income Infomation:

What's your monthly income *

If self-employed, what type of work *

Employer name (Self if self-employed) *

Selected Plan during quote:

What plan to enroll *

Life Insurance (optional) *

How much (optional) *

I agree to authorize James Gaffney to access and update my healthcare.gov account. I know and understand that this will effectively make said agent my agent of record. And I can, in the future rely on said agent for information and updates about my healthcare.gov account. *

Click here to Submit and Agree