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Application Type *

Agent currently assisting me *

Please begin entering your information below this line.

Personal Information:

Additional Info:

Name *

First

Last

Spouse's Name (if there is a spouse) *

First

Last

Date of Birth *

Spouse's Date of Birth *

Physical address *

Line 1

Line 2

City

State

Zip Code

Country

P.O. BOX or Alternate Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Spouse's Email *

Phone Number *

Spouse's Phone# *

Who needs coverage?

Do you need Coverage *

Yes No, I already have coverage

Does your spouse need coverage? *

Do any dependents need coverage? *

Additional Info *

Will you file a joint or single on next year's taxes? *

How do you file *

How does your spouse file *

Tell us about your tax dependent(s):

How many dependents will you file on your taxes *

List full name and date of birth for each dependent...... (add Social if dependent needs coverage as well) *

Dependent Address/if different *

Line 1

Line 2

City

State

Zip Code

Country

What's your race (optional) *

What's you spouse's race (optional) *

You can still verify each dependent's race

What was your assigned sex at birth? (Optional) This can be found on an original birth certificate or similar document. *

What's your gender identity? (Optional) *

What's your sexual orientation? (Optional) *

Your Social Security Number (Optional) *

If spouse needs coverage, what's your his/her Social Security number *

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

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 *

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

Tax Information:

Your annual gross income on 2025 taxes *

Your spouse's annual gross income on 2025 taxes *

Your current income source *

Spouse's current income source *

If self-employed, what type of work *

Self-employed spouse, type of work *

Employer name (Self if self-employed) *

Spouse's employer name *

Employer's phone# *

Spouse's employer's phone# *

How much do you pay monthly for student loans *

How much does spouse pay monthly student loans *

Do you smoke or use any other tobacco products *

Does your spouse smoke or use any other tobacco products *

Please list any dependents who smoke *

Selected Plan during quote:

What plan to enroll *

Estimated plan cost *

Separate Dental (optional) *

What plan (optional) *

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. *

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