Do You Need Health Insurance? We Can Help You Apply For Quality And Affordable ACA Coverage.

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Dental and Vision

Prescription Drugs

Tax Credit

Maternity Health

Health Management Programs

If You Would Like Our Assistance, Please Fill Out This Consent Form.

Your Name *

First

Last

Your Phone Number *

Your Email Address *

Today's Date *

Name of Primary Household Contact or Authorized Representative *

Check The Box To Agree With This Consent Statement *

I, the primary household contact or authorized representative, authorize Timothy Rose to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: 1. Searching for an existing Marketplace application; 2. 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; 3. Providing ongoing account maintenance and enrollment assistance, as necessary; or 4. Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by e-mailing Timothy Rose at tj@aspire65.com

Type Your Signature *

Request Information. Fill Out The ACA Proposal Form.

Name of Primary Household Contact or Authorized Representative *

First

Last

Zip Code *

Phone Number *

Email *

Primary Applicant Birthday *

Projected 2024 Annual Household Income Including All Income Earners *

If you underestimate your 2024 income on your application, you may be required to return a portion of your subsidy when filing your taxes. If you overestimate your income, you may have higher costs such as insurance premiums, copays and deductibles for your health insurance coverage than is necessary.

Number of Household Members *

First and last name, date of birth, relationship to you, and sex of all other applicants. *

Which applicants use tobacco? *

Which applicants are pregnant? *

Which applicants are the parent of a child under 19? *

Which applicants are eligible for other coverage? *

Which doctors and hospitals need to be in network? *

What prescription drugs need to be covered? *

Do you want dental and vision coverage? *

Call (913) 631-6450 (TTY:711) to Speak With a Licensed Agent.