Health Insurance Form Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country County * Date of Birth * MM DD YYYY Gender * Male Female Phone * (###) ### #### Email * Tobacco * Yes No Sometimes Income Tax Filing Status * Single Married Filing Joint Head of Household Married Filing Sperate Dependents How many Dependents will you file on your tax return next year? Kids, Relatives, Parents. 1 Dependent 2 Dependents 3 Dependents 4 Dependents 5 Dependents None Tax Filing Report * Which will you use to file your income tax next year? W2 1099/ Self Employed Social Security Social Security Diasbility Pension Long-term Disability Investment Income Other Yearly Income * What is your anticipated yearly income Between $14,600-$19,999 Between $20,000-$24,999 Between $25,000-$29,999 Between $30,000-$34,999 Between $35,000-$39,999 Between $40,000-$44,999 Between $45,000-$49,999 Between $50,000-54,999 Between $55,000-$59,999 $100K + Hard to tell/Don't know Ancillary Will you need any or the following additional benefits? Dental Vision Life Insurance $10k-$50k FYI Please note we may need to call you for a better understanding of your benefit eligibility, if so the call will come from 912-644-0111. Disclaimer Client Consent & Disclaimer for Health Insurance Quoting and Enrollment I, [Client Full Name], hereby authorize Bright Professional Advisors and/or their licensed representatives to collect necessary personal and household information for the purpose of providing health insurance quotes and assisting with my application and enrollment in a health insurance plan through the Affordable Care Act (ACA) Marketplace or other applicable insurance platforms. I understand and agree to the following: Consent to Assist: I authorize the above agent(s) to act on my behalf during the quoting and enrollment process, including submitting my application, verifying my eligibility for subsidies, and helping me select a suitable health plan. No Government Affiliation: I acknowledge that the agent(s) assisting me are not employees of any federal or state government agency. Accuracy of Information: I affirm that the information I provide will be truthful and accurate to the best of my knowledge. I understand that false or incomplete information may affect my eligibility or cause delays in coverage. Plan Responsibility: I understand that it is ultimately my responsibility to review and confirm my health insurance plan selection, including benefits, costs, and provider networks, before finalizing my enrollment. Communication Authorization: I consent to receive communications via phone, text, or email from the agent(s) for the purpose of discussing health insurance options, updates, or related matters. Enrollment in a health insurance plan through the Affordable Care Act (ACA) Marketplace is subject to eligibility requirements and application deadlines. Information provided during enrollment must be accurate and complete to ensure eligibility and correct subsidy calculation. This site and its representatives are not affiliated with or endorsed by the U.S. government or the federal Marketplace. We are a private entity offering assistance with plan comparison and enrollment. By using our services, you consent to communication via phone, email, or text regarding your insurance options. Coverage is not guaranteed until confirmed by the insurance provider. For official information, please visit HealthCare.gov. Privacy Statement: Your personal information will be collected, stored, and used in accordance with our Privacy Policy. We value your privacy and will not sell or share your data with unaffiliated third parties without your consent, except as required to fulfill your request for a quote or as otherwise permitted by law. Thank you!Your form has been submitted and is being processed.
