Elite Prime Health

Are You Looking For An Individual Plan Or Family Plan? *

Individual Plan

Family Plan

First Name *

Last Name *

Email *

Phone *

Date of Birth *

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

Agent Consent

I authorize Elite Prime Health to be my health insurance agent for myself and my household. This allows Elite Prime Health to enroll me, or my family, in a Qualified Health Plan on the Federally Facilitated Marketplace. By agreeing to this, I give permission for Elite Prime Health to use my confidential information for the following purposes:

Search for an existing Marketplace application.
Complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs.
Provide ongoing account maintenance and enrollment assistance.
Respond to inquiries from the Marketplace regarding my application. The Agent will keep my personal information private and secure, using it only for the purposes listed above. I confirm that the information I provide on my application will be accurate to the best of my knowledge. I understand that I am not obligated to share additional personal information beyond what is required for the application. I can revoke or modify my consent at any time by emailing [email protected]
I acknowledge your request to enroll me in the most suitable health plan available based on your expertise. If zero premium plans are unavailable, I authorize you to enroll me in the next best available plan. I grant you access to my healthcare.gov account for submitting necessary information. By signing below, I confirm my understanding and agreement to the terms outlined in this attestation.

Agent of Record: Elite Prime Health

NPN: 18854510

Phone Number: (561) 859-8322

Email Address: [email protected]

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By signing below I have read and agree to the text above. I also agree to the privacy policy that is linked below *

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Are you a legal resident of the United States? *

Yes

What is your gender? *

Male

Female

Address *

City *

Zip code *

State *

Your Annual Income *

Name of Your Employer *

Are you currently on Medicare or Medicaid? *

Yes

Does Your Job Or Your Spouses Job Offer Health Insurance? *

Yes

Are you a tobacco user? *

Yes

Please Select your Marital Status *

Single

Married

Do You File Your Tax Return Jointly or Separately?

Jointly

Separately

Spouse Information

Spouse's First Name *

Spouse's Last Name *

Spouse's Gender *

Male

Female

Spouse Date of Birth *

Is Your Spouse a U.S. Citizen? *

Yes

Spouse Information

Spouse's Annual Income

Spouse's Employer

Is Your Spouse a Tobacco User? *

Yes

Would You Like To Enroll Your Spouse? *

Yes

Do you have tax dependents (typically children)? *

Yes

Enter Tax Dependent's Information Below

Full Name *

Date of Birth *

Gender: *

Male

Female

Annual Income *

Name of Employer *

Tobacco User? *

Yes

Do you wish to enroll this dependent as well? *

Yes

Enter Tax Dependent's Information Below

Full Name *

Date of Birth *

Gender: *

Male

Female

Annual Income *

Name of Employer *

Tobacco User? *

Yes

Do you wish to enroll this dependent as well? *

Yes

Enter Tax Dependent's Information Below

Full Name *

Date of Birth *

Gender: *

Male

Female

Annual Income *

Name of Employer *

Tobacco User? *

Yes

Do you wish to enroll this dependent as well? *

Yes

Enter Tax Dependent's Information Below

Full Name *

Date of Birth *

Gender: *

Male

Female

Annual Income *

Name of Employer *

Tobacco User? *

Yes

Do you wish to enroll this dependent as well? *

Yes

Enter Tax Dependent's Information Below

Full Name *

Date of Birth *

Gender *

Male

Female

Annual Income *

Name of Employer *

Tobacco User? *

Yes

Do you wish to enroll this dependent as well? *

Yes

In order to enroll you we must be able to verify your identity through healthcare.gov. All data provided is 100% secure and encrypted.

Please provide 9 Digit Social Security Number with no dashes

Primary Applicant's Social Security Number *

If you wish to enroll your spouse please provide his or her SSN. If you do not have a spouse or do not wish to enroll spouse please ignore this field.

LAST STEP

Marketplace Consent

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, 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 2024 tax year. If I’m married at the end of 2024, 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. Steve Pierre or Elite Prime Health will use my information to complete the Marketplace application on my behalf. 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.

Please use your finger to sign below and submit your application: *

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