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Your 2024 Employment

Your Employment Information*
EmployedUnemployedReceiving Social Security

Your Employer Information

Your Monthly Social Security Income

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Medicaid/Medicare?

Are you currently on Medicaid or Medicare? *
YesNo

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.

Thank you for taking the time to complete this survey.

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What is your Marital Status?

Marital Status*
SingleMarriedDivorcedWidowed

Spouse's Information

Spouse's Employment

EmployedUnemployedSocial Security Benefits

Do You Want Your Spouse Covered On This Policy? *

YesNo

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Your Dependents

Do you want Children Covered on The Policy*
YesNo

Your Child's Information

Child's Full Name

Child's Date of Birth

Child age

If there are multiple dependents, please list additional information here

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Your Doctor Information

Do you have a primary doctor you see regularly*
YesNo

Your Doctor Information

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Final Step.....Almost Done!

What is your current age?*

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*

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Your 2024 Employment

Medicaid/Medicare?

Thank you for taking the time to complete this survey.

What is your Marital Status?

Spouse's Information

Spouse's Employment

Do You Want Your Spouse Covered On This Policy? *

Your Dependents

Your Child's Information

Your Doctor Information

Your Doctor Information

Almost Done! Let's Get Your Info

Final Step.....Almost Done!