AFFORDABLE AMERICAN HEALTH CARE

Get NEW Subsidized MarketPlace ObamaCare Now!

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications.

One of our Marketplace Specialists will Process your application to get you the best coverage possible

First Name

Last Name

Date of birth

Male or Female

Have you used tobacco 4 or more times a week for the past 6 months?

YES

Phone *

Email *

Address *

City *

State *

Postal code *

Marital Status *

Single

Married

Divorced

Widowed

Spouse's Name

Spouse's DOB

Has your spouse used tobacco 4 or more times a week for the past 6 months?

Yes

Spouse's Employment

Employed

Self-Employed

Social Security Benefits

Unemployed

Spouse's 2022 Estimated Monthly Income* PLEASE INCLUDE EVEN IF YOU DO NOT WANT THEM ON YOUR HEALTH INSURANCE POLICY

Do you want your spouse covered on this policy?

Yes

Spouse's Social Security #?

Your Employment Information *

Employed

Unemployed

Receiving Social Security

Employer Name

2022 Estimated Monthly Income

SSI Monthly Income *

Are you claiming any dependents on your taxes for 2022?

Yes

Child's Full Name *

Child's DOB *

Child's SSN *

if there are multiple dependents, please list additional information here

Doctor's Full Name

Doctor's City

What is your social security #? *

Confirmation *

By Clicking this box, you attest that all of the information is true and correct to the best of your knowledge. You are also giving affordableamericanhealthcare.com the permission to process your application with the information given to us.

Signature *

Clear