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It's NOW time to provide your current life changes so that we may update your 2024 Health Insurance Marketplace Application. Keep in mind, last minute household census forms, if submitted on December 14th and 15th, may not guarantee insurance coverage effective 01/01/24. All clients will be enrolled in the order that forms are received. Open enrollment is from November 1st to January 15th, 2024. Your Health Insurance effective date will be January 1st, 2024 if enrolled before 12/15/2023.
Update your household information
Please be as detailed as possible with your answers.
1. Primary First Name
*
2. Primary Last Name
*
3. Will your Spouse be covered on your Individual plan in 2024?
*
Yes
No
Not Married
Divorced
Widowed
4. Spouse First Name (if applicable)
5. Spouse Last Name
If you have no dependents / children, skip and go to question 24.
Otherwise, list all children or dependents in the household and answer corresponding questions.
6. Child #1 Full Name
7. Will you claim this child on your 2024 income tax return? (last filing date: April 15, 2025)
Yes
No
8. Will child #1 be covered on your Individual plan in 2024?
Yes
No
9. Child #2 Full Name
10. Will you claim this child on your 2024 income tax return? (last filing date: April 15, 2025)
Yes
No
11. Will child #2 be covered on your Individual plan in 2024?
Yes
No
12. Child #3 Full Name
13. Will you claim this child on your 2024 income tax return? (last filing date: April 15, 2025)
Yes
No
14. Will child #3 be covered on your Individual plan in 2024?
Yes
No
15. Child #4 Full Name
16. Will you claim this child on your 2024 income tax return? (last filing date: April 15, 2025)
Yes
No
17. Will child #4 be covered on your Individual plan in 2024?
Yes
No
18. Child #5 Full Name
19. Will you claim this child on your 2024 income tax return? (last filing date: April 15, 2025)
Yes
No
20. Will child #5 be covered on your Individual plan in 2024?
Yes
No
21. Child #6 Full Name
22. Will you claim this child on your 2024 income tax return? (last filing date: April 15, 2025)
Yes
No
23. Will child #6 be covered on your Individual plan in 2024?
Yes
No
Update or Confirm Primary Applicant Residence Address and Contact Information
24. Resident Address
*
25. City
*
26a. State
*
AL
FL
GA
IL
KS
MO
NC
NE
OH
OK
TN
TX
UT
Other
-
26b. Local County
27. Zip/Postal Code
*
28. Preferred Phone Number
*
29. Mailing Address, if diffent than Resident Address so that you recieve Insurance Medical Cards
30. Most Current Email Address
Re-type Email Address
Tobacco Use
31. (Primary) Are you a tobacco user? (four or more times a week within the past 6 months)
*
Yes
No
32. (Spouse) Are you a tobacco user? (four or more times a week within the past 6 months)
*
Yes
No
Doesn't Apply
33. New changes or corrections to your household or individual members for 2024 (check last box if none):
*
Correction to name, date of birth, or Social Security number
Change in disability status
Change of tax filing status
Change of citizenship or immigration status
Birth or adoption
Placing a child for adoption or foster care
Intentions of becoming pregnant
Pending Marriage or divorce
A child on your plan turning age 26 in 2024
A person will turned age 65 in 2024
Death of a household member in 2023
Gaining or losing a dependent some other way
Moving to a new permanent address.
None of the Above
34. If you checked any of the buttons above, provide a short answer here.
2024 Projected Household Income (Those that didn't qualify for tax credit assistance in 2023, may qualify in 2024)
35. (Primary) How much are you projecting to earn in 2024?
For W-2 earners provide your estimated gross income.
For Self employed, provide an estimated income after expenses.
Also, include Tax-exempt Social Security benefits.
More info:
https://www.healthcare.gov/income-and-household-information/how-to-report/
*
36. (Spouse) If married, how much are you projecting to earn in 2024?
Refer to question 35 for examples
and link assistance.
37. What is your total estimated household income for 2024? Add all incomes in household and enter here.
*
38. Do you or does your spouse's employer contribute a certain dollar amount to a Health Reimbursement Arrangement (HRA). This money is designed to pay for qualifying medical expenses. For some types of HRA, you or your spouse can also use the money to pay monthly premiums for a health plan you buy yourself.
*
Yes
No
39. If yes, how much do you and or does your spouse's employer contribute per month?
40. What is your employment status?
*
Job
Self-Employed
Other Income source
41. (Primary) If you have a job, who is your current employer?
42. (Primary) What is your employer's phone number?
43. (Spouse) If your spouse has a job, who is the current employer?
44. (Spouse) What is the employer's phone number?
45. If you are Self-Employed, what is your profession or trade?
46.
Please provide any additional detailed information prior to re-enrolling your 2024 Health Insurance Marketplace Application.
47. Primary Insured Signature
*
48.
After reading this disclosure statement, use your mouse on your PC or index finger on your phone to sign your name on the signature line below:
ACA Letter Of Authorization Legal Disclosure:
This statement is intended only to provide clarity to the public regarding existing requirements under the law.
Purpose Statement: Registered agents and brokers assisting consumers, applying for and enrolling in Marketplace coverage must document consumer consent prior to accessing or updating their Marketplace information.
I give my permission to Apollo Insurance Group and/or it’s representatives in this case to serve as the health insurance agent or broker on behalf of myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace.
By consenting to this agreement, I authorize the above-mentioned agent or broker to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:
-Searching for an existing Marketplace application
-C
ompleting 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 help pay for Marketplace premiums
-Providing ongoing account maintenance and enrollment assistance, as necessary
-Responding to inquiries from the Marketplace regarding my Marketplace application.
I understand that the agent or
broker
will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agent or broker will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.
I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge.
I understand that I do not have to share additional personal information about myself or my health with my agent or broker beyond what is required on the application for eligibility and enrollment purposes.
I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent in writing at any time by contacting Apollo Insurance Group and/or it’s representatives.
By signing this form on the line below, I am authorizing my agent of record, Philip Kathol NPN 16957396, to access my marketplace application and enroll me and or family members in a 2024 major medical health insurance plan through the federal marketplace.
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