2025 Open Enrollment

Primary Contact

First Name *

Middle Name (Optional)

Last Name *

Suffix (Optional)

Date of Birth *

Gender *

Male

Female

Street Address *

Apt #

City *

State *

Zip code *

County *

Email *

Phone *

Are you a smoker? *

Yes

Social Security Number *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages and phone calls from Luis Ortiz if needed.

Do you currently have health insurance? *

Yes

Are you also interested in dental & vision coverage options? *

Yes

Household Information

Who needs health coverage? *

Single Plan

Family Plan

Please Select your Marital Status *

Single

Married

Does your spouse need coverage? *

Yes

Spouse Information

Spouse's First Name *

Spouse's Middle Name

Spouse's Last Name *

Spouse Date of Birth *

Spouse's Gender *

Male

Female

Spouse's Job (If applicable)

Spouse's Annual Income *

Spouse's Social Security Number *

Do you have any dependents? *

Yes

Enter Tax Dependent's Information Below

Dependent's Full Name *

Dependent's Date of Birth *

Dependent's Gender: *

Male

Female

Would you like to enroll this dependent? *

Yes

Do you plan to claim this dependent on your tax return? *

Yes

Enter Tax Dependent's Information Below

Dependent's Social Security Number *

Enter Tax Dependent's Information Below

Dependent's Full Name *

Dependent's Date of Birth *

Dependent's Gender: *

Male

Female

Do you plan to claim this dependent on your tax return? *

Yes

Would you like to enroll this dependent? *

Yes

Enter Tax Dependent's Information Below

Dependent's Social Security Number *

Enter Tax Dependent's Information Below

Dependent's Full Name *

Dependent's Date of Birth *

Dependent's Gender: *

Male

Female

Do you plan to claim this dependent on your tax return? *

Yes

Would you like to enroll this dependent? *

Yes

Enter Tax Dependent's Information Below

Dependent's Social Security Number *

Enter Tax Dependent's Information Below

Dependent's Full Name *

Dependent's Date of Birth *

Dependent's Gender: *

Male

Female

Do you plan to claim this dependent on your tax return? *

Yes

Would you like to enroll this dependent? *

Yes

Enter Tax Dependent's Information Below

Dependent's Social Security Number *

Enter Tax Dependent's Information Below

Dependent's Full Name *

Dependent's Date Of Birth *

Dependent's Gender: *

Male

Female

Do you plan to claim this dependent on your tax return? *

Yes

Would you like to enroll this dependent? *

Yes

Enter Tax Dependent's Information Below

Dependent's Social Security Number *

Is everybody a United States citizen? *

Yes

Household Income / Tax Filings

Primary Applicant's Job *

Do you plan to file taxes single or jointly? *

Single

Jointly

Jointly Tax Filing

Spouse's Legal First & Last Name *

Spouse's Date of Birth *

Almost Complete...

(Optional) If you have any additional preferences or anything that is important to you when we enroll in you a plan, please write below:

LAST STEP

Please provide your full name and signature for both agreements below.

Agent Consent

I authorize Luis Ortiz to be my health insurance agent for myself and my household. This allows Luis Ortiz to enroll me, or my family, in a Qualified Health Plan on the Federally Facilitated Marketplace. By agreeing to this, I give permission for Luis Ortiz to use my confidential information for the following purposes:

Search for an existing Marketplace application.
Complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs.
Provide ongoing account maintenance and enrollment assistance.
Respond to inquiries from the Marketplace regarding my application. The Agent will keep my personal information private and secure, using it only for the purposes listed above. I confirm that the information I provide on my application will be accurate to the best of my knowledge. I understand that I am not obligated to share additional personal information beyond what is required for the application. I can revoke or modify my consent at any time by emailing
I acknowledge your request to enroll me in the most suitable health plan available based on your expertise. If zero premium plans are unavailable, I authorize you to enroll me in the next best available plan. I grant you access to my healthcare.gov account for submitting necessary information. By signing below, I confirm my understanding and agreement to the terms outlined in this attestation.

Agent of Record: Luis Ortiz

NPN: 19952883

Email Address: [email protected]

Primary Applicant's Full Name *

You may use your finger to sign below

By signing below I have read and agree to the text above. I also agree to the privacy policy that is linked below *

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Marketplace Consent

I must provide accurate information for eligibility and may need to provide proof. If I’m enrolled in Marketplace coverage and later found to have other qualifying health coverage, my Marketplace plan will be terminated automatically. I permit the Marketplace to use my income data for 5 years to determine my eligibility for assistance. I’m not eligible for a premium tax credit if I have other qualifying health coverage. I must inform the Marketplace if I become eligible for other coverage to avoid repayment of the premium tax credit. I must file a federal income tax return for the 2025 tax year. If I’m married at the end of 2025, I must file a joint income tax return with my spouse. No one else will be able to claim me as a dependent. I understand, this does not constitute tax advice, and I should consult a tax advisor for tax-related matters. I consent to receive electronic notices and use electronic signatures during enrollment. I confirm I’m authorized for the provided phone number and agree to receive marketing calls/messages. Luis Ortiz or Luis Ortiz will use my information to complete the Marketplace application on my behalf. I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.

Primary Applicant's Full Name *

You may use your finger to sign below

By signing below I have read and agree to the text above. I also agree to the privacy policy that is linked below *

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