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Home
Auto
Business
Disability Income
Health
Property
Life
Contact Us
Who we are
- Partners
Blog

👤 Primary Applicant

What is your full legal first name? *

Do you have a middle name you'd like to include?

What is your last name? *

Do you use a suffix (like Jr., Sr., III)? If so, what is it?

What is your full date of birth? *

What is your Gender? (Male or Female) *

Male
Female
No elements found. Consider changing the search query.
List is empty.

Are you applying for health coverage today? *

Yes

No

Do have Social Security Number *

Yes

No

What is your Social Security Number? *

Is Primary Applicant a U.S Citizen? *

Yes

No

⚠️ Important: A valid document is required to continue. Please upload the required document and select "Yes" to confirm you’ve uploaded it. You will not be able to proceed with your quote request until both actions are completed. Document that can be submitted: Permanent Green Card or Employment Authorization Card

Primary Applicant Immigration Document *

USCIS No. / Alien No. *

Primary Applicant Immigration Document confirmation *

Yes

No

Primary Applicant Naturalization Status *

Yes

No

⚠️ Important: A valid document is required to continue. Please upload the required document and select "Yes" to confirm you’ve uploaded it. You will not be able to proceed with your quote request until both actions are completed. Document that can be submitted: US Passport, Certificate of Naturalisation or Certificate of Citizenship.

Primary Applicant Citizenship Document *

Primary Applicant Citizenship Document Upload *

Yes

No

🏠 Home Address

What is your complete street address, including any apartment or unit number? *

What city do you live in? *

What state is that in? *

What is your ZIP code? *

Is Your Mailing Address Same As Your Home Address? *

Yes

No

what is your mailing address? *

☎️ Contact Information

What is the best email address to reach you? *

What is your primary phone number? *

Is that a home, work, or mobile number? *

Home

Work

Mobile

What language do you prefer for written communication? *

English
Spanish
No elements found. Consider changing the search query.
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What language do you prefer to speak? *

How would you like to receive important updates about your application? *

Paper notices in the mail

Emails and texts

Email only

Text only

Would you like to check if this household qualifies for cost savings based on income? *

Yes
No
No elements found. Consider changing the search query.
List is empty.

Marital Status *

SINGLE
MARRIED
DIVORCED
WIDOW
No elements found. Consider changing the search query.
List is empty.

Will your spouse be applying? *

Yes
No
No elements found. Consider changing the search query.
List is empty.

SPOUSE FIRST NAME *

SPOUSE LAST NAME *

SPOUSE GENDER *

male
female
No elements found. Consider changing the search query.
List is empty.

SPOUSE BIRTHDAY *

SPOUSE SSN *

Is your spouse a US Citizen? *

Yes

No

⚠️ Important: A valid document is required to continue. Please upload the required document and select "Yes" to confirm you’ve uploaded it. You will not be able to proceed with your quote request until both actions are completed. Document that can be submitted: Permanent Green Card, Employment

Spouse Immigration Document *

Spouse USCIS No / Alien No. *

Confirm Spouse Immigration Document Upload *

Yes

No

Is Spouse a Naturalized Citizen? *

Yes

No

Spouse Citizenship Document Upload *

Confirm Spouse Citizenship Document Upload *

Yes

No

How many people live in your household including yourself? *

0
1
3
4
5
6
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DEPENDENT 1 FIRST NAME *

DEPENDENT 1 LAST NAME *

DEPENDENT 1 BIRTHDATE *

DEPENDENT 1 GENDER *

male
female
No elements found. Consider changing the search query.
List is empty.

Does Dependent 1 Has SSN *

Yes

No

DEPENDENT 1 SSN *

Add Dependent 2 *

Yes
No
No elements found. Consider changing the search query.
List is empty.

DEPENDENT 2 FIRST NAME *

DEPENDENT 2 LAST NAME *

DEPENDENT 2 GENDER *

male
female
No elements found. Consider changing the search query.
List is empty.

DEPENDENT 2 BIRTHDATE

Does Dependent 2 Have SSN *

Yes

No

DEPENDENT 2 SSN *

Add Dependent 3 *

Yes
No
No elements found. Consider changing the search query.
List is empty.

DEPENDENT 3 FIRST NAME *

DEPENDENT 3 LAST NAME *

DEPENDENT 3 BIRTHDATE *

Does Dependent 3 Have SSN *

Yes

No

DEPENDENT 3 SSN

Add Dependent 4 *

Yes
No
No elements found. Consider changing the search query.
List is empty.

DEPENDENT 4 FIRST NAME *

DEPENDENT 4 LAST NAME *

DEPENDENT 4 BIRTHDATE *

DEPENDENT 4 GENDER *

MALE
FEMALE
No elements found. Consider changing the search query.
List is empty.

Does Dependent 4 Have SSN *

Yes

No

DEPENDENT 4 SSN

Add dependent 5 *

Yes
No
No elements found. Consider changing the search query.
List is empty.

DEPENDENT 5 FIRST NAME *

DEPENDENT 5 LAST NAME *

DEPENDENT 5 GENDER *

MALE
FEMALE
No elements found. Consider changing the search query.
List is empty.

DEPENDENT 5 BIRTHDATE *

Does Dependent 5 Have SSN *

Yes

No

DEPENDENT 5 SSN

Add Dependent 6 *

Yes
No
No elements found. Consider changing the search query.
List is empty.

DEPENDENT 6 FIRST NAME *

DEPENDENT 6 LAST NAME *

DEPENDENT 6 GENDER *

MALE
FEMALE
No elements found. Consider changing the search query.
List is empty.

DEPENDENT 6 BIRTHDATE *

Does Dependent 6 Have SSN *

Yes

No

DEPENDENT 6 SSN *

Do you plan to file a federal income tax return for 2025? *

Yes

No

Will you be filing jointly with a spouse? *

Yes

No

Will you be claiming any dependents? *

Yes

No

List dependents You Will Be Claiming *

Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Dependent 6

Are you currently earning any income? *

Yes

No

Type of Income *

Wages or salary
Self-employment income
Social Security benefits (retirement, disability)
Retirement or pension income
Unemployment benefits
Alimony received
Capital gains or dividends
Rental or royalty income
Other income
No elements found. Consider changing the search query.
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How often do you receive income? (e.g., weekly, biweekly, monthly, yearly) *

Weekly
Biweekly
Monthly
Yearly
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What is your job title or job description? *

What is your employer’s address (if known)?

What is the name of your employer? *

Confirm Employment *

Yes

No

What is the name of your business? *

What type of business is it? *

Business Address *

You confirm that the business information provided is correct? *

Yes

No

Please enter the estimated annual amount *

$5,000 - 15,900
$20,000 - $25,000
$25,000 - $30,000
$30,000 - $35,000
$35,000 - $40,000
$40,000 - $45,000
$45,000 - $50,000
$50,000 - $55,000
$55,000 - $60,000
$60,000 - $65,000
$65,000 - $70,000
$70,000 - $75,000
No elements found. Consider changing the search query.
List is empty.

Are you currently enrolled in a health insurance plan? *

Yes
No
No elements found. Consider changing the search query.
List is empty.

If yes, what kind of plan do you have? (Marketplace, employer, Medicaid, etc.) *

Marketplace
Employer
Medicaid
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When will that coverage end? *

Do you confirm that all the information provided today is true to the best of your knowledge? *

Yes

No

Do you agree to allow the Marketplace to use your information to determine eligibility? *

Yes

No

Do you understand you may be required to file a federal tax return and reconcile premium tax credits if received? *

Yes

No

Will you report any changes to income, address, or household within 30 days? *

Yes

No

Do you give permission for Georgia Access to end duplicate Medicare coverage if it applies? *

Yes

No

Do you consent to your information being shared with Medicaid or PeachCare? *

Yes

No

Please type or state your full legal name to sign this application electronically. *

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770-884-8117

[email protected]

555 North Point Center E Suite 400, Alpharetta, GA 30022

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Phone No.

770-884-8117

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770-884-8117

Email

[email protected]

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