Your 2024 Employment

Your Employment Information*
EmployedUnemployedReceiving Social Security

[group employer_group]

Your Employer Information

[/group]

[group ssn_income_group]

Your Monthly Social Security Income

[/group]

Medicaid/Medicare?

Are you currently on Medicaid or Medicare? *
YesNo

[group medicare_group]

You said you have Medicaid or Medicare coverage. Is that correct?

Yes, I have Medicare or MedicaidNo, I must have misclicked. I do not have Medicare or Medicaid OR I will be losing Medicaid coverage shortly and need ACA coverage.
[/group]

[group overlay-group]

[/group]

What is your Marital Status?

Marital Status*
SingleMarriedDivorcedWidowed

[group spouse_group]

Spouse's Information

Do You Want Your Spouse Covered On This Policy? *

YesNo
[/group]

Your Dependents

Do you want Children Covered on The Policy*
YesNo

[group dependent_group]

Your Child's Information

[/group]

Your Doctor Information

Do you have a primary doctor you see regularly*
YesNo

[group doctor_group]

Your Doctor Information

[/group]

Almost Done! Let's Get Your Info

Final Step.....Almost Done!

I agree that I have read this attestation and by signing below request that Joseph Donnantuoni or its agency affiliates enroll me and/or my family in the best $0 ACA plan, to access my healthcare.gov account and submit based on the details provided. (Never use similar forms asking for your SS number)

I AgreeI Disagree

Please sign below*