Health Insurance Tax Credits RWIG - Find Health Insurance Coverage

I give permission to Right Way Insurance Group LLC and it’s affiliates to access and/or create my application for health insurance on the Federally Facilitated Marketplace (FFM) based on the information I am providing below.

Yes, I give Permision.

Do you have insurance through your employer, Medicare, Medicaid or VA?

Yes No

Main Applicant Date of Birth

First Name

Last Name

Phone Number

Address

City

State

Zip Code

Social Security Number

Gender

Male Female

Marital Status

Single Married

Spouse First Name

Spouse Last Name

Spouse Date of Birth

Spouse SSN (Only if adding to the plan)

Spouse Gender

Male Female

Will you be claiming any dependents on your taxes in 2023?

Yes No

First Name

Last Name

Gender

Male Female

Date of Birth

SSN (if adding to plan)

Add Dependent

What is your estimated Household Income for 2023?

Is this

Monthly Yearly

* If your plan choice is not available, a licensed agent will choose the best available $0 option for you

Income Verification

Do you Agree with the Income Verification?

Yes, I Agree

Consent to Enrollment; Verification of Information

Do you Agree with the Consent?

Yes, I Agree

Authorization and Tax attestation

Do you Agree with Authorization and Tax attestation?

Yes, I Agree

Consent Acknowledgement

Do you Agree with Consent Acknowledgement?

Yes, I Agree

Signature

By signing, I grant permission to act on my behalf and that of my entire household in matters related to enrollment in a Qualified Health Plan via the Federally Facilitated Marketplace. This authorization also extends to any authorized representative or power of attorney acting on my behalf. The agents empowered by this agreement are Right Way Insurance Group LLC and/or its affiliates. These agents are authorized to locate existing Marketplace applications, complete applications for eligibility in various plans and programs, provide necessary ongoing maintenance, and respond to inquiries about my application from the Marketplace. I understand and agree that my personally identifiable information will be accessed and used solely for the objectives specified in this document. I attest that all the details I provide for the purposes of eligibility and enrollment will be accurate to the best of my ability. I am under no obligation to disclose additional personal or health-related information beyond what is required for these applications. My consent remains effective until I choose to revoke it. For any modifications or to revoke this consent, I can email help@rightwayinsurancegroup.com or by calling (888) 261-0585.

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First Name

%first-name%

Applicant Date of Birth

%mm-dd-YYYY%

Last Name

%Last-name%

Gender

%gender%

Marital Status

%marital status%

Phone

%Phone%

%Email%

Address

%Address%

City

%City%

State

%state%

Zip Code

%zipcode%

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Spouse Name

%spouse full name%

Spouse DOB

%spouse DOB%

Spouse Gender

%spouse gender%

Spouse SSN

%spouse SSN%

Dependant 1 Name

%dependent-1-name%

Dependent-1-gender

%dependent-1-gender%

Dependent-1-DOB

%dependent-1-DOB%

Dependent-1-relationship

%dependent-1-relationship%

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Household Income

%householdincome%

Monthly or Yearly

%monthly-yearly%

$0 Plan Option

%plan-option%

Income Verification

%income-verification% ( I Agree)

Consent to Enrollment

%Consent-to-Enrollment% ( I Agree)

Authorization and Tax attestation

%Authorization-Taxattestation% (I Agree)

Permission to Peace Tree Insurance LLC

%permissionPeaceTreeInsurance% (YES)

Do you have insurance through your employer, Medicare, Medicaid or VA?

%Do you have insurance through your employer, Medicare, Medicaid or VA? %

Consent Acknowledgement

%Consent Acknowledgement %

$0 Health Insurance Plan + Premium Tax Credit

Check Eligibility and Enroll Today

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Review Your Application

Review Your Application