OPEN ENROLLMENT IS NOW!

Complete your enrollment for 2025 today and ensure you are fully covered before open enrollment ends!

Answer the Following Questions ACCURATELY to Authorize Your Application for FREE/SUBSIDIZED Health Insurance!

Legal First Name *

Legal Last Name *

Phone Number *

Email *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Your information is 100% secure & encrypted with us. We will NEVER sell or rent your data out to anyone. Your information will only be shared with Amir Zamani with AffordableHealthLink in order to enroll you in the best/cheapest health plan available to you and your family based on the information in the survey.

What is your Physical Address?

Street Address *

Postal Code *

City *

State *

Primary Applicant Date of Birth *

Gender *

Estimated HOUSEHOLD 2025 Annual Income *

Please select a range above for your ESTIMATED 2025 TOTAL TAX HOUSEHOLD gross (before tax) income for all individuals that will be enrolled on the health plan. This includes yourself, MARRIED spouse, and any child that will be enrolled or are your dependent you claim on your taxes. If you are self-employed or own a business, PLEASE ENTER YOUR NET PROFIT AFTER ALL EXPENSES/DEDUCTIONS.

I acknowledge that if I am earning less than 100% of the Federal Poverty Line, I am actively seeking and expect to bring my annual income at or above 100% of the Federal Poverty Line. Click here to view FPL chart.

Are you currently on Medicaid OR Medicare? *

Yes

Have you had Medicaid Denied Within Last 90 Days? *

Yes

Medicaid Denied Date *

Please enter best estimated guess if unable to locate exact date.

Are you Employed Currently? *

Yes

Employer Name *

Does Your Employer Offer Health Insurance? *

Important - If you have job-based insurance now or get an offer for job-based insurance, you won’t qualify for savings on a Marketplace plan if the job-based plan is considered affordable and meets minimum standards. Most job-based plans meet these standards. If you have a Marketplace plan and get an offer of health insurance through a job, you may no longer qualify for savings on your Marketplace plan even if you don’t accept the job-based coverage offer.

If your job offers health insurance and you reject it, you will be liable to pay back your tax credit for your Marketplace plan at the end of the year!

Do you have a Spouse? *

Yes

Spouse Legal First Name *

Spouse Legal Last Name *

Spouse Date of Birth MM-DD-YYYY *

Spouse Gender *

Spouse Social Security Number *

Do you want to enroll your Spouse on the Health plan? *

Yes

If you are NOT legally married, then please submit a seperate survey and we will enroll your spouse on their own health plan. If you ARE legally married, then you will need to be filing taxes JOINTLY to qualify for a tax credit subsidy.

Will You File Your Taxes Jointly Or Separately With Your Spouse? *

Jointly

Separately

Important - If you are married, you must file taxes jointly to be eligible for tax credits towards your insurance, even if the spouse will not be on the plan.

Is your Spouse Employed? *

Yes

Spouses Employer Name *

Spouse Income *

Does your Spouses Employer Offer Health Insurance? *

Do you have any Dependents? *

Yes

**IMPORTANT** We will need to know all dependent's information whether they will be enrolling in the health plan or not. Accurate dependent information will help us determine your subsidy amount (if any) you will receive.

ONLY SELECT YES IF DEPENDENTS ARE CLAIMED BY YOU ON TAX RETURN.

Dependent 1 Legal First Name *

Dependent 1 Legal Last Name *

Dependent 1 Gender *

Dependent 1 Date of Birth MM-DD-YYYY *

Relationship to Dependent 1 *

Dependent 1 on Medicaid or CHIP? *

Yes

Dependent 1 Denied Medicaid or CHIP? (Last 90 days) *

Yes

Enroll Dependent 1 on the Health Plan? *

Yes

Do you have a 2nd Dependent? *

Yes

Dependent 2 Legal First Name *

Dependent 2 Legal Last Name *

Dependent 2 Gender *

Dependent 2 Date of Birth MM-DD-YYYY *

Relationship to Dependent 2 *

Dependent 2 on Medicaid or CHIP? *

Yes

Dependent 2 Denied Medicaid or CHIP? (Last 90 days) *

Yes

Enroll Dependent 2 on the Health Plan? *

Yes

Do you have a 3rd Dependent? *

Yes

Dependent 3 Legal First Name *

Dependent 3 Legal Last Name *

Dependent 3 Gender *

Dependent 3 Date of Birth MM-DD-YYYY *

Relationship to Dependent 3 *

Dependent 3 on Medicaid or CHIP? *

Yes

Dependent 3 Denied Medicaid or CHIP? (Last 90 days) *

Yes

Enroll Dependent 3 on the Health Plan? *

Yes

Do You Have a 4th Dependent? *

Yes

Dependent 4 Legal First Name *

Dependent 4 Legal Last Name *

Dependent 4 Gender *

Dependent 4 Date of Birth MM-DD-YYYY *

Relationship to Dependent 4 *

Dependent 4 on Medicaid or CHIP? *

Yes

Dependent 4 Denied Medicaid or CHIP? (Last 90 days) *

Yes

Enroll Dependent 4 on the Health Plan? *

Yes

Do You Have a 5th Dependent? *

Yes

Dependent 5 Legal First Name *

Dependent 5 Legal Last Name *

Dependent 5 Gender *

Dependent 5 Date of Birth MM-DD-YYYY *

Relationship to Dependent 5 *

Dependent 5 on Medicaid or CHIP? *

Yes

Dependent 5 Denied Medicaid or CHIP? (Last 90 days) *

Yes

Enroll Dependent 5 on the Health Plan? *

Yes

Dependent 1 Social Security Number

Dependent 2 Social Security Number

Dependent 3 Social Security Number

Dependent 4 Social Security Number

Dependent 5 Social Security Number

If you have your child’s social and are ENROLLING them on the health plan, please enter it above so we can enroll them in the health plan. If you do not have your child’s social, please complete the application and we will reach out to you within 24 hrs to verify it as we will need this to fully enroll them into the plan.

I hereby grant my permission for Amir Zamani to act as my health insurance agent for both myself and my entire household, if applicable. This permission is specifically for the purpose of enrolling in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By agreeing to this arrangement, I authorize the aforementioned agent to access and utilize the confidential information provided by me, whether in writing, electronically, or via telephone, solely for one or more of 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 assist in paying for Marketplace premiums.
Providing ongoing account maintenance and enrollment assistance, as required.
Addressing inquiries from the Marketplace regarding my Marketplace application.
In the event that I already have a Marketplace plan, granting permission to switch to a more suitable plan if available. If I am already on the optimal plan, I request that the agent take over as my agent of record from this point forward, unless notified of any changes.

I understand that the agent will not utilize or disclose my personally identifiable information (PII) for any purposes other than those explicitly enumerated above. The agent will take necessary measures to ensure the confidentiality and security of my PII when collecting, initiating, and utilizing it for the aforementioned purposes. I affirm that the information I have furnished for my Marketplace eligibility and enrollment application is accurate to the best of my knowledge. I am aware that I am not obligated to provide additional personal information about myself or my health to my agent beyond what is necessary for the application for eligibility and enrollment.

I also understand that my consent remains in effect until I choose to revoke it, and I retain the right to revoke or notify my consent at any time by sending an email, text, or making a phone call to the following:

Name of Primary Writing Agent: Amir Zamani

Agent National Producer Number: 20731634

Phone Number: 702-353-3811

Email Address: [email protected]

Expiration Date: 11/01/2026

Authorization Signature *

Clear

I acknowledge and understand the following:

I must provide accurate information for eligibility and may need to provide proof.
If I'm enrolled in Marketplace coverage and later found to have other qualifying health coverage (e.g. Medicaid, Medicare, CHIP, job-based plan), my Marketplace plan will be terminated automatically.
I permit the Marketplace to use my income data for 5 years to determine my eligibility for assistance.
I'm not eligible for a premium tax credit if I have other qualifying health coverage.
I must inform the Marketplace if I become eligible for other coverage to avoid repayment of the premium tax credit.
I must file a federal income tax return for the 2025 tax year.
If I’m married at the end of 2025, I must file a joint income tax return with my spouse.
No one else will be able to claim me as a dependent
I understand, this does not constitute tax advice, and I should consult a tax advisor for tax-related matters.
I consent to receive electronic notices and use electronic signatures during enrollment.
I confirm I'm authorized for the provided phone number and agree to receive marketing calls/messages.
Amir Zamani will use my information to complete and submit the Marketplace application on my behalf
I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325)

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.

Primary Applicant's Social Security Number *

We need this to verify and complete your marketplace application - Please enter your FULL 9 digit SSN or we will not be able to submit your application!

Authorization Signature *

Clear

If your income for you/your family size falls within the ranges below, you can qualify for a $0 Health-Plan!

Current Contracted Carriers

(Not all carriers are shown below)

Current States We Service

Contact Us

(205) 627-3703

[email protected]

Privacy Policy

Data Collection: Our Agents 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.

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.

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.