GoVine - Health Insurance

ENTER YOUR DETAILS TO SEE IF YOU QUALIFY

Zip Code *

First Name *

Last Name *

Email *

Phone *

What is your address where we can mail the cards?

Address *

City *

State *

County *

Primary Date of Birth MM/DD/YYYY *

Are you a US Citizen? *

Yes

Primary Applicant's Social Security Number *

Who is your most recent employer? *

What is your estimated gross monthly income? *

This is your income before taxes. Must earn between $1,500 - $3,000 per month.

Do you have a spouse *

Yes

Spouse's Date of Birth MM/DD/YYYY *

Spouse Legal First Name *

Spouse Legal Last Name *

When Filing Taxes do you file? *

I file taxes with a spouse and/or children

I file taxes as an individual

Do you want to enroll your spouse? *

Yes

Do you have tax dependants? *

Yes

Dependent 1 Full Legal Name *

Dependent 1 Date of Birth MM-DD-YYYY *

Does your dependant have medicaid or CHIP? *

Yes

Does your dependant need coverage? *

Yes

Do You Have a 2nd Dependent? *

Yes

Dependent 2 Full Legal Name *

Dependent 2 Date of Birth MM-DD-YYYY *

Does your dependent have Medicaid or CHIP? *

Yes

Does your dependent need coverage? *

Yes

Do You Have a 3rd Dependent? *

Yes

Dependent 3 Full Legal Name *

Dependent 3 Date of Birth MM-DD-YYYY *

Does your dependent have Medicaid or CHIP? *

Yes

Does your dependent need coverage? *

Yes

Do You Have a 4th Dependent? *

Yes

Dependent 4 Full Legal Name *

Dependent 4 Date of Birth MM-DD-YYYY *

Does your dependent have Medicaid or CHIP? *

Yes

Does your dependent need coverage? *

Yes

Do You Have a 5th Dependent? *

Yes

Dependent 5 Full Legal Name *

Dependent 5 Date of Birth MM-DD-YYYY *

Does your dependent have Medicaid or CHIP? *

Yes

Does your dependent need coverage? *

Yes

Do you currently have a Marketplace Plan? *

Yes

I agree that I have read this attestation and I give my consent to GoVine Insurance LLC, Agency NPN 20888409 to serve as my agent of record for myself and my household, for the purpose of enrollment and re-enrollment in a qualified Health Plan offered by the Federally Facilitated Marketplace. I consent to allow the above mentioned agent to view and use my confidential information for the following purposes:

1. Search for an existing Marketplace Plan;

2. Complete an application for eligibility and enrollment in a Marketplace Plan;

3. Provide ongoing maintenance, enrollment, and re-enrollment assistance;

4. Respond to inquiries from the Marketplace regarding my application.

5.Text or Email me with updates or changes to my Marketplace Plan when needed.

I confirm that the information I have shared is accurate and true for entry on my Marketplace Health Insurance Application. I have read and consent with the terms and understand the above mentioned agent will safely store and use my personal identifiable information for the above stated purposes, and by submitting this document I agree that my household income falls within the chart below that I do not have Medicare/Medicaid/TriCare/VA or Employer Coverage, and I do not use tobacco products, qualifying myself for Zero Premium Health Coverage. I understand my consent remains in full effect until I revoke it by emailing [email protected].

By providing my mobile number, I consent to receive SMS communications from GoVine Insurance LLC and or its subsidiaries. I can opt out of texts at any time by replying "STOP".

Authorization Date *

Authorization Signature *

Clear

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