Health | United National Benefits

How to get

$0 ACA/health coverage

without having to speak to an agent

or fill out out any confusing forms

Lets Start With Some Basic Questions.

Answer the Following Questions Accurately to Authorize Your Application!

First Name *

Last Name *

Email *

Cell Phone *

What is Your Physical Address?

Address *

City *

State *

Postal code *

Primary Date of birth *

Primary Applicants Social Security Number *

What is Your Gender *

I was found not eligible for Medicaid or CHIP in the last 90 days *

Yes

No

Do you have a doctor you would like to keep? *

Yes

No

Do You Have A Spouse? *

Yes

No

Spouse Full Name *

Spouse's Date of Birth *

Spouse Gender *

Do you want us to enroll your Spouse? *

Yes

No

Spouse Social Security *

Do You Have Dependents *

Yes

No

Dependet 1 Full Legal Name *

Dependent Gender *

Dependent Date of Birth *

Relationship to Dependent 1 *

Do you have a 2nd Dependent? *

Yes

No

Dependent 2 Gender *

Dependent 2 Date Of Birth *

Relationship to Dependent 2 *

Dependent 2 Full Name *

Do You Have a 3rd Dependent? *

Yes

No

Dependent 3 Full Name *

Dependent 3 Gender *

Dependent 3 Date of Birth *

Relationship to Dependent 3 *

Do you have a 4th Dependent? *

Yes

No

Dependent 4 Full Name *

Dependent 4 Gender *

Dependent 4 Date of Birth *

Relationship to Dependent 4 *

Do you want us to enroll them? *

Yes

No

Dependent 1 Social Security Number *

Dependent 2 Social Security Number

Dependent 3 Social Security Number

Dependent 4 Social Security Number

I agree that I have read this attestation and I give my permission to Juan Herrera to serve as my broker for myself and my family household, for the purpose of enrollment in a qualified health plan offered by federal facilitated marketplace. I consent to allow the above mentioned agent to view use my confidential information for the following purposes:

Signature *

Clear

Health Insurance Self Enrollment

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