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Answer the Following Questions Accurately to Authorize Your Application!

Primary First Name *

Primary Last Name *

Primary Cell Phone *

Primary Email *

Primary Date of Birth MM-DD-YYYY *

Primary Gender *

Primary Applicant's Social Security Number *

Do You Have A Spouse To Enroll? *

Spouse Legal First Name *

Spouse Legal Last Name *

Date of Birth MM-DD-YYYY *

Spouse Gender *

Spouse's Social Security Number *

Do You Have A Dependent To Enroll? *

Dependent 1 Full Legal Name *

Dependent 1 Gender *

Date of Birth MM-DD-YYYY *

Dependent 1 Social Security Number *

Do You Have A Second Dependent To Enroll? *

Dependent 2 Full Legal Name *

Dependent 2 Gender *

Date of Birth MM-DD-YYYY *

Dependent 2 Social Security Number *

Do You Have A Third Dependent To Enroll? *

Dependent 3 Full Legal Name *

Dependent 3 Gender *

Date of Birth MM-DD-YYYY *

Dependent 3 Social Security Number *

Do You Have A Fourth Dependent To Enroll? *

Dependent 4 Full Legal Name *

Dependent 4 Gender *

Date of Birth MM-DD-YYYY *

Dependent 4 Social Security Number *

Do You Have A Fifth Dependent To Enroll? *

Dependent 5 Full Legal Name *

Dependent 5 Gender *

Date of Birth MM-DD-YYYY *

Dependent 5 Social Security Number *

Do You Have A Sixth Dependent To Enroll? *

Dependent 6 Full Legal Name *

Dependent 6 Gender *

Dependent 6 Date of Birth MM-DD-YYYY *

Dependent 6 Social Security Number *

I give my permission to the agent listed below to serve as the health insurance agent or broker for myself and my entire household for purposes of enrollment in a Qualified Marketplace Health Plan. By consenting to this agreement, I also authorize said Agent to use the information provided by me in writing, electronically, or by telephone for the following purposes:

Searching for an existing Marketplace application: 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; Providing ongoing account maintenance and enrollment assistance, as necessary; or Responding to inquiries from the Marketplace regarding my Marketplace application for the next 60 months.

I understand that my consent remains in effect until I revoke it and I may revoke or modify my consent at any time by contacting my Agent at the following email address below or phone number below;

Name of Primary Writing Agent: Jarret Kerman

Phone Number: 802-454-3153

Email Address: Jarret@k4cares.com

Agent NPN: 20833956

SMS (Text Message) Consent:

By providing your mobile number, you consent to receive

SMS (text message) communications from Jarret Kerman.

Msg & data rates may apply. You can opt out at any time by replying "STOP".

By submitting this document, you agree the above information is true and accurate. Also that your income falls in the following chart, qualifying you for the Zero Premium Health Coverage.

*not all applicants qualify for the subsidies and/or $500 Rewards.

Upon signing & submitting this document I am confirming I DO NOT currently have Medicare, Medicaid, Group, federally recognized Tribes, or ANCSA shareholder Insurance Coverage. We cannot take any actions that jeopardize these types of coverage.

Authorization Date *

Authorization Signature *

Clear

Terms of Service:

By using our services, you agree to the following terms:

Representation: You grant the authorized agent, as mentioned in the attestation disclaimer, the authority to act on your behalf concerning health insurance matters, including enrollment, renewals, and related decisions.

Accuracy: You confirm that all information provided is true and accurate. False or misleading information can lead to the termination of services.

Revocation: Your consent remains in effect until you revoke it. You may revoke or modify your consent at any time.

Limitation of Liability: The authorized agent and associated entities are not liable for any errors or omissions in the services provided or for any damages, including indirect or consequential damages.

Privacy Policy:

Data Collection: We collect Personally Identifiable Information (PII) solely for the purposes mentioned in our Comprehensive Attestation Agreement.

Data Protection: We are committed to ensuring the privacy and safety of your PII. Your data will not be shared for any purposes other than those explicitly stated in our agreement.

Income Attestation: We use your income information solely to determine eligibility for health insurance programs and potential subsidies.

TCPA Disclaimer:

By providing your phone number, you expressly consent to receive auto-dialed and/or pre-recorded telemarketing calls, text messages, and/or emails from the authorized agent mentioned in the attestation disclaimer at the phone number and email address you provided, including for marketing purposes. You understand that consent is not a condition of purchase. Message and data rates may apply.

$0 Premium Healthcare- finish your application now.

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