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First Name *

Last Name *

Date of Birth *

Cell Phone *

Email *

What is your Gender? *

Male

Female

Address *

Street Address

City

State

Country

Postal code

Mailing address the same? *

Yes

No

What is your Mailing Address? *

Do you use tobacco? *

Yes

No

Select YES if you've used tobacco 4 or more times a week for the past 6 months. You may pay more for insurance, but if you get a related illness and do not report you are tobacco user, your insurance can deny you coverage.

What is your marital status? *

Spouse's Name *

Does your spouse need covered on this policy? *

Yes

No

Spouse's Date of Birth *

Spouse's SSN *

Spouse's Employment *

Employed

Unemployed

Receiving Social Security

Spouse's Estimated Annual Income Last Year *If Any*

$

Will you be filing taxes jointly with your spouse for this year's tax period? *

Yes

No

SS Income Amount *

$

How often do you get this amount? *

Will you claim any dependents on your taxes? *

Yes

No

Please provide this information even if your dependents do not need coverage

Dependent 1 *

Full Name
Date of Birth
SSN
Gender

Add Dependent 1 Coverage to this policy? *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 2 *

Full Name
Date of Birth
SSN
Gender

Add Dependent 2 Coverage to this policy? *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 3 *

Full Name
Date of Birth
SSN
Gender

Add Dependent 3 Coverage to this policy? *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 4 *

Full Name
Date of Birth
SSN
Gender

Add Dependent 4 Coverage to this policy? *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 5 *

Full Name
Date of Birth
SSN
Gender

Add Dependent 5 Coverage to this policy? *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add Another Dependent? *

Yes

No

Dependent 6 *

Full Name
Date of Birth
SSN
Gender

Add Dependent 6 Coverage to this policy? *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add additional dependents? *

Yes

No

Dependent Names & Gender (press enter after each gender) *

Dependent Birthdays (press enter after each DOB) *

Dependent SSNs (press enter after each) *

Your Social Security Number *

I give my permission to Carolina ACA LLC and any of it’s licensed agents to serve as the health insurance agent or broker for 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 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:1. Searching for an existing Marketplace application;2. Completing 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;3. Providing ongoing account maintenance and enrollment assistance, as necessary; or4. Responding to inquiries from the Marketplace regarding my Marketplace application.I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent 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 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.

Signature *

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Peak Insurance is an insurance broker that connects individuals with insurance providers. Products and services are provided exclusively by the providers. Descriptions are for informational purposes only and subject to change. Insurance plans may not be available in all states. By submitting your phone number, you are giving Peak Insurance permission to communicate with you via automatically-sent text message.