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How many people need coverage? *

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First Name *

Last Name *

To avoid issues with identity verification, please provide your Maiden Name:

Maiden Name

Main Applicant Date of Birth *

Gender

Male

Female

Are you married? *

Yes

No

Are You A United States Citizen?

Yes

No

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Yes I'm Married:

Spouse Name

To avoid issues with identity verification, please provide your Maiden Name:

Spouse Maiden Name

Does Spouse Need Coverage?

Yes

No

Spouse Date of Birth

Spouse Social Security Number (no dashes)

If you choose NOT to provide your Social Security Number today, you will have 90 days to provide your social to the Marketplace. If they do not receive your information within 90 days. The Marketplace will terminate your insurance We'll send reminders via email, text and phone calls once you've received your ID cards

Name of Employer for Spouse

Spouse Expected Income Per Month (Be Accurate - Income Will Be Verified By Healthcare.gov)

$

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MAIN APPLICANT INFORMATION

Cell Phone Number *

Email *

ADDRESS INFORMATION

Address (NOT your P.O. Box) *

City *

State *

Postal code *

County (Plans Vary by County) *

HOUSEHOLD INFORMATION

Social Security - Main Applicant

If your income is $0 (or less than the Federal Poverty Limit), you attest that your estimated income for 2023 will be at least the Federal Poverty Limit for your state and household requirements. If your income will be less than (or greater than) those limits, you agree to notify us or the marketplace of any changes or updates as soon as possible. Failure to notify us of any changes may result in your eligibility being affected.

Job Seeking

I Agree to notify Boost Health if my estimated income for 2023 changes.

Most Recent Employer (If you are self employed, Please type in "Self employed") *

Does Anyone Use Tobacco? If so who?

Please Be Accurate - Income Will Be Verified By Healthcare.gov

What is your monthly Gross Income *

$

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Do You Claim Any Dependents?

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Please Add Info for Dependent #1

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 2nd Dependent? *

Yes

No

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Please Add Info for Dependent #2

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 3rd Dependent? *

Yes

No

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Please Add Info for Dependent #3

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 4th Dependent? *

Yes

No

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Please Add Info for Dependent #4

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 5th Dependent? *

Yes

No

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Please Add Info for Dependent #5

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 6th Dependent? *

Yes

No

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Please Add Info for Dependent #6

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 7th Dependent? *

Yes

No

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Please Add Info for Dependent #7

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 8th Dependent? *

Yes

No

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Please Add Info for Dependent #8

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 9th Dependent? *

Yes

No

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Please Add Info for Dependent #9

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

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PLAN CHOICE

Check Box Below: *

YES! I give permission to apply for $0 premium health insurance!

AGREEMENTS

Please read the attestations below and sign if you agree.

I agree to have my information used and retrieved from government data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from government data sources.

I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage. Renewal of coverage

To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.

TAX ATTESTATION

I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: I must file a federal income tax return for the 2022 tax year.

I MUST FILE A FEDERAL INCOME RETURN FOR THE 2022 TAX YEAR.

If I’m married at the end of 2022, I must file a joint income tax return with my spouse. I also expect that: No one else will be able to claim me as a dependent on their 2022 federal income tax return. I’ll claim a personal exemption deduction on my 2022 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.

IF ANY OF THE ABOVE CHANGES

I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2022 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

PLEASE READ ATTESTATIONS BELOW BEFORE YOU SIGN AND SUBMIT YOUR APPLICATION:

I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by texting (AGENT NAME) at (AGENT CELL). I know a change in my information could affect eligibility for member(s) of my household.

If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost. You consent to the use of an electronic signature to sign all forms presented to you by [Boost] during the health insurance policy application process, unless and until you withdraw your consent to the use of electronic signatures by providing notice to the address below, and agree that this consent is effective on the date that you affix your signature below. By signing below, you agree to be legally bound as if you had signed this form and other documents with a handwritten signature, and you acknowledge that you have reviewed and agree to the above terms and conditions. If you have any questions, please contact us at privacy@boosthealthinsurance.com. Please signify your agreement with the foregoing by signing below.

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information. You consent to the use of an electronic signature to sign all forms presented to you by Boost Health Insurance, LLC. during the health insurance policy application process, unless and until you withdraw your consent to the use of electronic signatures by providing notice to the address below, and agree that this consent is effective on the date that you affix your signature below. By signing below, you agree to be legally bound as if you had signed this form and other documents with a handwritten signature, and you acknowledge that you have reviewed and agree to the above terms and conditions. If you have any questions, please contact Boost Health Insurance, LLC. at help@healthinsurancesolutions.org. Please signify your agreement with the foregoing by signing below. I hereby authorize Boost Health Insurance, LLC. to sign the application for Federally Facilitated Exchange health insurance on my behalf, and to store my electronic signature affixed below for purposes of doing so. I understand that at this time I have not yet applied for Federally Facilitated Exchange health insurance, and that Boost Health Insurance, LLC. will be using the information and consents I provide herein to fill out, sign on my behalf, and submit the Federally Facilitated Exchange application.

SIGN IN BOX TO SUBMIT APPLICATION *

Clear

I have read and agree to the terms above *

YES

NO