(803) 634-7368

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melissa@bassinsurancesolutions.com

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How many people need coverage? *

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Full Name *

Main Applicant Date of Birth *

Are you married?

Yes

No

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Yes I'm Married:

Spouse Name

Does Spouse Need Coverage?

Yes

No

Spouse Date of Birth

Spouse Social Security Number (no dashes)

If you choose NOT to provide your Social Security Number today, you will have 90 days to provide your social to the Marketplace. If they do not receive your information within 90 days. The Marketplace will terminate your insurance We'll send reminders via email, text and phone calls once you've received your ID cards

Name of Employer for Spouse

Spouse Expected Income Per Month (Be Accurate - Income Will Be Verified By Healthcare.gov)

$

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Do you want to apply for a subsidy to pay for your insurance?

Yes

No

SIGN UP ONLINE

MAIN APPLICANT INFORMATION

Cell Phone Number *

Email *

ADDRESS INFORMATION

Address (NOT your P.O. Box) *

City *

State *

Postal code *

County (Plans Vary by County) *

HOUSEHOLD INFORMATION

Social Security - Main Applicant

If you choose NOT to provide your Social Security Number today, you will have 90 days to provide your social to the Marketplace. If they do not receive your information within 90 days. The Marketplace will terminate your insurance We'll send reminders via email, text and phone calls once you've received your ID cards

Job Seeking

If making less than $1100/mo, I agree I am looking for a job making minimum wage or better

Most Recent Employer *

Expected Income Per Month (Be Accurate - Income Will Be Verified By Healthcare.gov) *

$

Does Anyone Use Tobacco? If so who?

Do you currently have Medicare, Medicaid, an employer policy or VA benefits? (you will NOT qualify for Obamacare subsidy if you qualify for Medicaid/Medicare/employer or VA plan.

Other Insurance? *

Yes

No

I attest that from this day forward (MELISSA BASS),NPN (18806223), will be the agent of record for my healthcare.gov insurance plan with the marketplace and will only be replaced by another agent if written notice is submitted to her.

Healthcare.gov Access *

Yes

No

Do you understand that if you’re not eligible for a $0 plan we will enroll you in the cheapest plan that is still affordable? (If you decide that you do not want this plan simply don’t pay the bill or call the insurance company to cancel.)

Free Plan Eligibility *

Yes

No

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Do You Claim Any Dependents?

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Please Add Info for Dependent #1

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 2nd Dependent? *

Yes

No

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Please Add Info for Dependent #2

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 3rd Dependent? *

Yes

No

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Please Add Info for Dependent #3

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 4th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #4

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 5th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #5

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 6th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #6

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 7th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #7

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 8th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #8

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 9th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #9

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

SIGN UP ONLINE

PLAN CHOICE

Check Box Below: *

YES! I give permission to apply for free health insurance!

AGREEMENTS

Please read the attestations below and sign if you agree.

I agree to have my information used and retrieved from government data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from government data sources.

I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage. Renewal of coverage

To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.

TAX ATTESTATION

I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: I must file a federal income tax return for the 2022 tax year.

I MUST FILE A FEDERAL INCOME RETURN FOR THE 2022 TAX YEAR.

If I’m married at the end of 2022, I must file a joint income tax return with my spouse. I also expect that: No one else will be able to claim me as a dependent on their 2022 federal income tax return. I’ll claim a personal exemption deduction on my 2022 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.

IF ANY OF THE ABOVE CHANGES

I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2022 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

PLEASE READ ATTESTATIONS BELOW BEFORE YOU SIGN AND SUBMIT YOUR APPLICATION:

I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by texting (AGENT NAME) at (AGENT CELL). I know a change in my information could affect eligibility for member(s) of my household.

If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.

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.

SIGN IN BOX TO SUBMIT APPLICATION *

I have read and agree to the terms above *

YES

NO

We work with every carrier in the state and will place you in the best option in your situation.

Our goal is to place you in a $0 PREMIUM plan. Please answer the questions below:

You Are One Step From

New Coverage

SIGN UP ONLINE

How many people need coverage? *

- select an option -

1
2
3
4
5
6
7
8
9
10
No elements found. Consider changing the search query.
List is empty.

SIGN UP ONLINE

Full Name *

Main Applicant Date of Birth *

Are you married?

Yes

No

SIGN UP ONLINE

Yes I'm Married:

Spouse Name

Does Spouse Need Coverage?

Yes

No

Spouse Date of Birth

Spouse Social Security Number (no dashes)

If you choose NOT to provide your Social Security Number today, you will have 90 days to provide your social to the Marketplace. If they do not receive your information within 90 days. The Marketplace will terminate your insurance We'll send reminders via email, text and phone calls once you've received your ID cards

Name of Employer for Spouse

Spouse Expected Income Per Month (Be Accurate - Income Will Be Verified By Healthcare.gov)

$

SIGN UP ONLINE

Do you want to apply for a subsidy to pay for your insurance?

Yes

No

SIGN UP ONLINE

MAIN APPLICANT INFORMATION

Cell Phone Number *

Email *

ADDRESS INFORMATION

Address (NOT your P.O. Box) *

City *

State *

Postal code *

County (Plans Vary by County) *

HOUSEHOLD INFORMATION

Social Security - Main Applicant

If you choose NOT to provide your Social Security Number today, you will have 90 days to provide your social to the Marketplace. If they do not receive your information within 90 days. The Marketplace will terminate your insurance We'll send reminders via email, text and phone calls once you've received your ID cards

Job Seeking

If making less than $1100/mo, I agree I am looking for a job making minimum wage or better

Most Recent Employer *

Expected Income Per Month (Be Accurate - Income Will Be Verified By Healthcare.gov) *

$

Does Anyone Use Tobacco? If so who?

Do you currently have Medicare, Medicaid, an employer policy or VA benefits? (you will NOT qualify for Obamacare subsidy if you qualify for Medicaid/Medicare/employer or VA plan.

Other Insurance? *

Yes

No

I attest that from this day forward (MELISSA BASS),NPN (18806223), will be the agent of record for my healthcare.gov insurance plan with the marketplace and will only be replaced by another agent if written notice is submitted to her.

Healthcare.gov Access *

Yes

No

Do you understand that if you’re not eligible for a $0 plan we will enroll you in the cheapest plan that is still affordable? (If you decide that you do not want this plan simply don’t pay the bill or call the insurance company to cancel.)

Free Plan Eligibility *

Yes

No

SIGN UP ONLINE

Do You Claim Any Dependents?

- select -

0
1
2
3
4
5
6
7
8
9
No elements found. Consider changing the search query.
List is empty.

SIGN UP ONLINE

Please Add Info for Dependent #1

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 2nd Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #2

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 3rd Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #3

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 4th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #4

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 5th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #5

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 6th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #6

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 7th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #7

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 8th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #8

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

Need to add a 9th Dependent? *

Yes

No

SIGN UP ONLINE

Please Add Info for Dependent #9

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Socials are only needed if dependent is applying for insurance

SIGN UP ONLINE

PLAN CHOICE

Check Box Below: *

YES! I give permission to apply for free health insurance!

AGREEMENTS

Please read the attestations below and sign if you agree.

I agree to have my information used and retrieved from government data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from government data sources.

I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage. Renewal of coverage

To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.

TAX ATTESTATION

I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: I must file a federal income tax return for the 2022 tax year.

I MUST FILE A FEDERAL INCOME RETURN FOR THE 2022 TAX YEAR.

If I’m married at the end of 2022, I must file a joint income tax return with my spouse. I also expect that: No one else will be able to claim me as a dependent on their 2022 federal income tax return. I’ll claim a personal exemption deduction on my 2022 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.

IF ANY OF THE ABOVE CHANGES

I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2022 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

PLEASE READ ATTESTATIONS BELOW BEFORE YOU SIGN AND SUBMIT YOUR APPLICATION:

I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by texting (AGENT NAME) at (AGENT CELL). I know a change in my information could affect eligibility for member(s) of my household.

If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.

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.

SIGN IN BOX TO SUBMIT APPLICATION *

I have read and agree to the terms above *

YES

NO

We work with every carrier in the state and will place you in the best option in your situation.

Our goal is to place you in a $0 PREMIUM plan. Please answer the questions below:

CARRIERS WE REPRESENT

THESE ARE ONLY A FEW OF THE CARRIERS WE SHOP TO MAKE SURE YOU HAVE THE PLAN THAT FITS YOUR NEEDS!

We have helped families with their Marketplace application since 2014. We have created this form to assist you through the enrollment process.

We will never call you. Only a text or email if there is an issue with your new health insurance.

You can call us at any time

We are a licensed Independent Agency operating in over 10 states to help ensure you get the help you deserve. The average time to complete an online application is 4 minutes. We will then find you the right plan and have you covered with an Insurance carrier from the Affordable Care Act Marketplace if you qualify. We will communicate with you via text and email. You can always call us if you'd like.

Melissa Bass, the founder, has been in the insurance space for the last 33 years and has helped thousands of people lower their premiums and find affordable insurance. As an independent agent, we work with multiple companies so that we can always find the fit that is right for you.

Click Here To Call

This form is to be used to help you insure you and your family. The information provided must be accurate for the subsidies to be accurate. Our job is impossible with incorrect information. Submitting this form tells us that to the best of your knowledge all of the above information is accurate. You will not receive any phone calls from Bass Insurance Solutions. We will however text or email you if the Marketplace requests anything from you. You will also receive everything in the mail. Let us know if you need any further assistance.