OPEN ENROLLMENT IS NOW!

Complete your enrollment for 2025 today and ensure you are fully covered before open enrollment ends!

Answer the Following Questions ACCURATELY to Authorize Your Application for FREE/SUBSIDIZED Health Insurance!

Legal First Name *

Legal Last Name *

Phone Number *

Email *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Your information is 100% secure & encrypted with us. We will NEVER sell or rent your data out to anyone. Your information will only be shared with a licensed health agent on our team in order to enroll you in the best/cheapest health plan available to you and your family based on the information in the survey.

What is your Physical Address?

Street Address *

City *

State *

Postal Code *

Primary Applicant Date of Birth *

Gender *

Estimated HOUSEHOLD 2025 Annual Income *

Please select a range above for your ESTIMATED 2025 TOTAL TAX HOUSEHOLD gross (before tax) income for all individuals that will be enrolled on the health plan. This includes yourself, MARRIED spouse, and any child that will be enrolled or are your dependent you claim on your taxes. If you are self-employed or own a business, PLEASE ENTER YOUR NET PROFIT AFTER ALL EXPENSES/DEDUCTIONS.

I acknowledge that if I am earning less than 100% of the Federal Poverty Line, I am actively seeking and expect to bring my income for 2024 at or above 100% of the Federal Poverty Line. Click here to view FPL chart.

Are you currently on Medicare? *

Yes

Have you had Medicaid Denied Within Last 90 Days? *

Yes

Medicaid Denied Date *

Are you Employed Currently? *

Yes

Employer Name *

Does your employer offer health insurance? *

Important - If you have job-based insurance now or get an offer for job-based insurance, you won’t qualify for savings on a Marketplace plan if the job-based plan is considered affordable and meets minimum standards. Most job-based plans meet these standards.

If you have a Marketplace plan and get an offer of health insurance through a job, you may no longer qualify for savings on your Marketplace plan even if you don’t accept the job-based coverage offer.

If your job offers health insurance and you reject it, you will be liable to pay back your tax credit for your Marketplace plan at the end of the year!

Do you have a Spouse? *

Yes

Spouse Legal First Name *

Spouse Legal Last Name *

Spouse Gender *

Spouse Date of Birth MM-DD-YYYY *

Spouse Social Security Number *

Do you want to enroll your Spouse on the Health plan? *

Yes

Will You File Your Taxes Jointly Or Separately With Your Spouse? *

Important - If you are married, you must file taxes jointly to be eligible for tax credits towards your insurance, even if the spouse will not be on the plan.

Is your Spouse employed? *

Yes

Spouses Employer Name *

Spouse Income *

Does your Spouses Employer Offer Health Insurance? *

Do you have any Dependents? *

Yes

**IMPORTANT** We will need to know all dependent's information whether they will be enrolling in the health plan or not. Accurate dependent information will help us determine your subsidy amount (if any) you will receive.

ONLY SELECT YES IF DEPENDENTS ARE CLAIMED BY YOU ON TAX RETURN.

Dependent 1 Legal First Name *

Dependent 1 Legal Last Name *

Dependent 1 Gender *

Dependent 1 Date of Birth MM-DD-YYYY *

Relationship to Dependent 1

Dependent 1 on Medicaid or CHIP? *

Yes

Dependent 1 Denied Medicaid or CHIP? (Last 90 days) *

Yes

Enroll Dependent 1 on the Health Plan? *

Yes

Dependent 1 Social Security Number *

Do You Have A 2nd Dependent? *

Yes

Dependent 2 Legal First Name *

Dependent 2 Legal Last Name *

Dependent 2 Gender *

Dependent 2 Date of Birth MM-DD-YYYY *

Relationship to Dependent 2

Dependent 2 on Medicaid or CHIP? *

Yes

Dependent 2 Denied Medicaid or CHIP? (Last 90 days) *

Yes

Enroll Dependent 2 on the Health Plan? *

Yes

Dependent 2 Social Security Number *

Do You Have A 3rd Dependent? *

Yes

Dependent 3 Legal First Name *

Dependent 3 Legal Last Name *

Dependent 3 Gender *

Dependent 3 Date of Birth MM-DD-YYYY *

Relationship to Dependent 3

Dependent 3 on Medicaid or CHIP? *

Yes

Dependent 3 Denied Medicaid or CHIP? (Last 90 days) *

Yes

Enroll Dependent 3 on the Health Plan? *

Yes

Dependent 3 Social Security Number *

Do You Have A 4th Dependent? *

Yes

Dependent 4 Legal First Name *

Dependent 4 Legal Last Name *

Dependent 4 Gender *

Dependent 4 Date of Birth MM-DD-YYYY *

Relationship to Dependent 4

Dependent 4 on Medicaid or CHIP? *

Yes

Dependent 4 Denied Medicaid or CHIP? (Last 90 days) *

Yes

Enroll Dependent 4 on the Health Plan? *

Yes

Dependent 4 Social Security Number *

Do You Have A 5th Dependent? *

Yes

Dependent 5 Legal First Name *

Dependent 5 Legal Last Name *

Dependent 5 Gender *

Dependent 5 Date of Birth MM-DD-YYYY *

Relationship to Dependent 5

Dependent 5 on Medicaid or CHIP? *

Yes

Dependent 5 Denied Medicaid or CHIP? (Last 90 days) *

Yes

Enroll Dependent 5 on the Health Plan? *

Yes

Dependent 5 SSN *

I hereby grant my permission for Brad Gillett to act as my health insurance agent for both myself and my entire household, if applicable. This permission is specifically for the purpose of enrolling in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By agreeing to this arrangement, I authorize the aforementioned agent to access and utilize the confidential information provided by me, whether in writing, electronically, or via telephone, solely for one or more of the following purposes:

Searching for an existing Marketplace application.
Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan, or other government insurance affordability programs, such as Medicaid and CHIP, or advance tax credits to assist in paying for Marketplace premiums.
Providing ongoing account maintenance and enrollment assistance, as required.
Addressing inquiries from the Marketplace regarding my Marketplace application.
In the event that I already have a Marketplace plan, granting permission to switch to a more suitable plan if available. If I am already on the optimal plan, I request that the agent take over as my agent of record from this point forward, unless notified of any changes.

I understand that the agent will not utilize or disclose my personally identifiable information (PII) for any purposes other than those explicitly enumerated above. The agent will take necessary measures to ensure the confidentiality and security of my PII when collecting, initiating, and utilizing it for the aforementioned purposes. I affirm that the information I have furnished for my Marketplace eligibility and enrollment application is accurate to the best of my knowledge. I am aware that I am not obligated to provide additional personal information about myself or my health to my agent beyond what is necessary for the application for eligibility and enrollment.

Brad Gillett may receive compensation for assisting you with your marketplace insurance. This compensation can range from $15 - $30/month/member, depending on the carrier chosen and the state you reside in. Additionally, Brad Gillett might also receive indirect compensation through bonuses or contest payouts, which vary based on the carrier and state.

I also understand that my consent remains in effect until I choose to revoke it, and I retain the right to revoke or notify my consent at any time by sending an email, text, or making a phone call to the following:

Name of Primary Writing Agent: Brad Gillett

Agent National Producer Number: 2825764

Phone Number: (941) 205-9044

Email Address: [email protected]

Authorization Signature *

Clear

I acknowledge and understand the following:

I must provide accurate information for eligibility and may need to provide proof.
If I'm enrolled in Marketplace coverage and later found to have other qualifying health coverage (e.g. Medicaid, Medicare, CHIP, job-based plan), my Marketplace plan will be terminated automatically.
I permit the Marketplace to use my income data for 5 years to determine my eligibility for assistance.
I'm not eligible for a premium tax credit if I have other qualifying health coverage.
I must inform the Marketplace if I become eligible for other coverage to avoid repayment of the premium tax credit.
I must file a federal income tax return for the 2025 tax year.
If I’m married at the end of 2025, I must file a joint income tax return with my spouse.
No one else will be able to claim me as a dependent
I understand, this does not constitute tax advice, and I should consult a tax advisor for tax-related matters.
I consent to receive electronic notices and use electronic signatures during enrollment.
I confirm I'm authorized for the provided phone number and agree to receive marketing calls/messages.
Brad Gillett will use my information to complete and submit the Marketplace application on my behalf
I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325)

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.

Check the box below *

I have reviewed the Attestation Explanations

The attestation explanations are located HERE

Primary Applicant's Social Security Number *

Authorization Signature *

Clear

If your income for you/your family size falls within the ranges below, you can qualify for a $0 Health-Plan for 2025!

Current Contracted Carriers

(Not all carriers are shown below)

Current States We Service

Previous Client's Insurance Examples!

(Plans shown below may not be available in your exact state/zip code)

Texas, 78521 Zip Code
2 Person Household
$21,900/Yr Annual Household Income

Tennessee, 38357 Zip Code
1 Person Household
$19,800/Yr Annual Household Income

Louisiana, 70062 Zip Code
1 Person Household
$21,200/Yr Annual Household Income

Louisiana, 70517 Zip Code
2 Person Household
$43,000/Yr Annual Household Income

Contact Us

(941) 205-9044

[email protected]

Privacy Policy

Data Collection: Our Agents collect Personally Identifiable Information (PII) solely for the purposes mentioned in our Comprehensive Attestation Agreement.

Data Protection: We are committed to ensuring the privacy and safety of your PII. Your data will not be shared for any purposes other than those explicitly stated in our agreement.

Income Attestation: We use your income information solely to determine eligibility for health insurance programs and potential subsidies.

Terms of Service

By using our services, you agree to the following terms:

Representation: You grant the authorized agent, as mentioned in the attestation disclaimer, the authority to act on your behalf concerning health insurance matters, including enrollment, renewals, and related decisions.

Accuracy: You confirm that all information provided is true and accurate. False or misleading information can lead to the termination of services.

Revocation: Your consent remains in effect until you revoke it. You may revoke or modify your consent at any time.

Limitation of Liability: The authorized agent and associated entities are not liable for any errors or omissions in the services provided or for any damages, including indirect or consequential damages.

TCPA Disclaimer

By providing your phone number, you expressly consent to receive auto-dialed and/or pre-recorded telemarketing calls, text messages, and/or emails from the authorized agent mentioned in the attestation disclaimer at the phone number and email address you provided, including for marketing purposes.

You understand that consent is not a condition of purchase.

Message and data rates may apply.