Obamacare Application

OBAMACARE

PRIMARY APPLICANT

Today's Date

First Name

Middle Name

Last Name

Phone Number

Date of Birth

Address Line 1

Address Line 2

City

State

Zip Code

Country

Applicant Immigration Status

Social Security #

HOUSEHOLD

Please list the names of all other household members on your income tax return who are applying for insurance.

Household 1

First Name

Middle Name

Last Name

Date of Birth

Gender

Immigration Status

SSN

Household 2

First Name

Middle Name

Last Name

Date of Birth

Gender

Immigration Status

SSN

Household 3

First Name

Middle Name

Last Name

Date of Birth

Gender

Immigration Status

SSN

Household 4

First Name

Middle Name

Last Name

Date of Birth

Gender

Immigration Status

SSN

Other Information

If married, do you file a joint income tax return?

Is anyone a full-time student?

Does your employer offer insurance coverage?

Does anyone smoke?

Taxable Income Information on those who are working or receiving social security benefits.

Complete name

Employer

Phone number

Expected income

Complete name

Employer

Phone number

Expected income

Complete name

Employer

Phone number

Expected income

Binder Payment

Bank name

Account Type

Name on card

Card Number

Expiration date

CVV

Routing number

Account number

Signature

I understand that this is not a government facility. I give authorization to allow my agent to assist me in completing my application and to enroll me in an insurance plan for 2022/2023. I allow the insurance agency and agent to contact me in the future.I hereby certify that, to the best of my knowledge, the provided information is true and accurate. *

Confirmation

About Us

ELTINE MULTI SERVICES is primarily a financial service company helping you and your family with planning and choosing proper plans that can keep their lives sustainable.

Our services include Life Insurance, Health Insurance, [we mainly specialized in Obamacare], Car Insurance, Will and Testimony, Investment, and College Planning.

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