Affordable
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First Name
*
Last Name
*
Phone
*
Email
*
Date of birth
Male or Female
M
F
Have you used tobacco 4 or more times a week for the past 6 months
YES
NO
Address
*
City
*
State
*
Postal code
*
Marital Status
*
Single
Married
Divorced
Widowed
Spouse's Name
Spouse's DOB
Has your spouse used tobacco 4 or more times a week for the past 6 months?
Yes
No
Spouse's Employment
Employed
Self-Employed
Social Security Benefits
Unemployed
Spouse's 2022 Estimated Monthly Income* PLEASE INCLUDE EVEN IF YOU DO NOT WANT THEM ON YOUR HEALTH INSURANCE POLICY
Do you want your spouse covered on this policy?
Yes
No
Spouse's Social Security #?
Your Employment Information
Employer Name
2022 Estimated Monthly Income
SSI Monthly Income
Are you claiming any dependents on your taxes for 2022?
Yes
No
Child's Full Name
Child's DOB
Child's SSN
if there are multiple dependents, please list additional information here
Doctor's Full Name
Doctor's City
In Order to get a Cost Sharing Reduction and an Advanced Premium Tax Credit you will need to file a tax return for the upcoming year. Will you file a tax return for the coming year?
Yes
No
What is your social security #?
Confirmation
*
By Clicking this box, you attest that all of the information is true and correct to the best of your knowledge. You are also giving affordableamericanhealthcare.com the permission to process your application with the information given to us.
Signature
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