Affordable Care Connected

About Us
Affordable Health Insurance
Our Team
Contact Us
Get a quote

About Us
Affordable Health Insurance
Our Team
Contact Us
Get a quote

Get a quote

Affordable Care Connected

Self - Enrollment

Name

Birthday

Gender

Phone

Email Address

Address

City

State

Zip

User Identification

Are You a U.S. Citizen

Drivers License: Front

Drivers License: Back

Upload File

SSN

Authenticate SSN

Household Income

Employer Info

Job Title

Company Name

Expected Annual Income This Year

Additional Information

Are you a smoker?

Yes No

Is anyone applying for health coverage on this application CURRENTLY incarcerated
(detained or jailed)?

No, not currently incarcerated Yes, currently incarcerated

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

Agree Disagree

I know that I must tell the program I'll be enrolled in if the information I listed on this application changes. I know I can make changes in my Marketplace account or by calling (888) 244 -1129 I understand that a change in my information could affect my eligibility for member(s) of my household.

Agree Disagree

What are the most important benefits to you in your health insurance policy?

Notes

Do You Have Health Insurance?

Which Carrier?

When Did You Lose Coverage?

Marital Status

Dependents?

Spouse & Dependent

Spouse Dependent 1 Dependent 2 Dependent 3

In Addition To Healthcare Which Insurance Would You Like ?

Dental Life Insurance

Digital Consent Agreement

Do you authorize Affordable Care Connected to submit your Application to the Marketplace for your $0 per month health plan?

Yes No

Do you authorize Affordable Care Connected to update and make changes to your health plan, in order to keep your policy active or prevent you from losing coverage if needed?

Yes No

Do you authorize Affordable Care Connected to call, text, or email you when we need to update your policy and assist with documents the marketplace may require, such as your income letter?

Yes No

If the current plan you’re enrolling in today is not available at a $0 cost for the following years, do you authorize Affordable Care Connected to enroll you in the next best $0 health plan with the same or similar insurance provider that you are enrolling in today?

Yes No

Do you give consent and Authorize Affordable Care Connected to select and or choose a plan on behalf of the customer enrolling in this application?

Yes No

Notes Or Additional Dependents

Referred By

Name

Your Signature

Acceptance

By clicking ENROLL NOW, you consent and request to be enrolled by Affordable Care Connected Benefits Agency, LLC (dba Affordable Care Connected insurance agency), and their agents, they may contact you by phone, email and text/SMS to your home or mobile number(s) you provided, even if you provided a number that is registered on a National, State, or Private Do Not Call List.

Acceptance

You agree to receive automated Promotional and Transactional SMS.

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Affordable Care Connected is a team of skilled health insurance professionals who utilize cutting-edge digital technologies and provide a premium concierge experience to greatly simplify the health insurance enrollment process.

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Affordable Health Insurance

Contact info

1000 Brickell Avenue,
STE 715-1974,
Miami, FL 33131
866-535-0057
contact@smartinsuranceiq.com

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