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Date of birth *

What is your employment status? *

Are you currently on Medicare or Medicaid *

How much was your household income last year? *

What is your projected annual household income for this upcoming year? *

Do you currently have health insurance? *

Do you have a Primary Care Physician (Doctor) that you want to keep? *

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Physician's Practice Address *

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I hereby acknowledge my agreement to the contents of this attestation. By affixing my signature below, I respectfully request
this agent or its agency affiliates to enroll both myself and/or my family in the most optimal $0 ACA plan. Additionally, I authorize them to access my healthcare.gov account and submit the necessary information in accordance with the details provided.

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