Online Application

Let's Start with Basic Info

First Name *

Last Name *

Sex *

Male

Female

Your date of birth *

Phone *

Email *

Address (Please No Punctuation) (NO PO BOX's) *

City *

Postal code *

Your marital status *

Single

Married

Divorced

Widowed

Spouse's Name *

Spouse's DOB *

Spouse's Employment *

Spouse's 2024 Estimated Annual Income *If any

Do you want your Spouse covered on this policy? *

Spouse's Social Security Number? *

Personal employment information in 2024 *

Medicaid

Unemployed

Employed

Medicare

Can you please provide an ESTIMATE of your 2024 income? *

$0 - $22k

$23k - $25k

$26k - $30k

$31k - $36k

Employer Name *

Approximate Annual Income in 2024 *

Do you have children you claim on your taxes? *

Yes

No

First child's first and last name *

Child's DOB *

Do you have a second child? *

Yes

No

Second child's first and last name *

Second child's DOB *

Do you have a third child? *

Yes

No

Third child's first and last name *

Third child's DOB *

Do you have a fourth child? *

Yes

No

Fourth child's first and last name *

Fourth child's DOB *

Do you have a primary care doctor you see regularly? *

Yes

No

Doctors Full Name *

Doctors City *

Do you take any medications currently? *

Yes

No

What Medications do you take currently? *

Are you a smoker? *

Yes

No

Social Security Number (9 Digits) *

A Full 9 Digit Social is Required to Qualify

Your signature *

Clear

Easy Online Application For Quick & Easy Enrollment.

Affordable Plans with Exclusive Benefits

4 Out 5 People Get $0 Premiums Without Any Hassle

**Obtain Affordable Health Insurance through the**

Subsidized Marketplace in Indiana today!

An ACA Today licensed agent in your state will contact you in the event we need to fill in any gaps or correct anything that the Affordable Care Act does not accept.

We have a track record of thousands of policies issued every year with no hassle and quick turnaround times. We are an insurance broker that connects individuals, like yourself with insurance carriers. Not every Policy will come with the Healthy Rewards Card. To earn the rewards card, you may need to onboard with the carrier, have an annual checkup, complete online activities, and complete some health management. We are not associated or affiliated with Medicaid nor Medicare. Products and services are provided exclusively by the carrier or providers. Descriptions are for informational purposes only and are subject to change. Insurance plans and specific benefits may not be available in all states or even cities. By entering your phone number you are giving us permission to communicate with you via automatically-sent text message and phone call to verify any information the Affordable Care Act requires.

How it works

No calls, no hassle—just chat with our Agents.

Each application needs to be filled out completely and double verified after you choose your plan. A licensed agent will then communicate with you about any additional information they need. The day the plan is written and approved you will receive a text message with a copy of the plan, link to look up additional Doctors and Drugs, and a link to that carrier’s rewards program.

This will be followed up by an email from www.healthcare.gov as well as receiving all information and appropriate cards in the mail in 3-4 weeks . You are all set.

How it works

No calls, no hassle—just chat with our Agents.

Each application needs to be filled out completely and double verified after you choose your plan. A licensed agent will then communicate with you about any additional information they need. The day the plan is written and approved you will receive a text message with a copy of the plan, link to look up additional Doctors and Drugs, and a link to that carrier’s rewards program.

This will be followed up by an email from www.healthcare.gov as well as receiving all information and appropriate cards in the mail in 3-4 weeks . You are all set.

Our goal is to simplify the enrollment process. And enroll you with a $0 premium, which is dependent on your annual household income & state of residense.

4 out of 5 people qualify for $0 Permium

Let's start your enrollment Process Now.