Fruitful Financial

$0 Health insurance with $500 flex visa card

Get NEW Subsidized MarketPlace ObamaCare Now

Get NEW Subsidized

MarketPlace ObamaCare Now

No need to have your phone ringing off the hook with salesmEn

EASY ONLINE APPLICATION

One of our Marketplace Specialists will process your application to get you the best coverage possible

First Name *

Last Name *

Birthday *

Cell Phone *

Email Address *

Gender *

Male

Female

Are you pregnant or plan on becoming pregnant? *

Yes

No

How many babies are you expecting? *

Street Address *

City *

State *

Zip Code *

Mailing address the same? *

Yes

No

What is your Mailing Address? *

Do you use Tobacco? *

Yes

No

Select YES if you've used tobacco 4 or more times a week for the past 6 months. You may pay more for insurance, but if you get a related illness and do not report you are tobacco user, your insurance can deny you coverage.

What is your Marital Status *

Please complete information even if your spouse does not need coverage

Spouse's Name *

Does your Spouse need covered on this policy? *

Yes

No

Spouse's DOB *

Spouse's SSN *

Spouse's Employment *

Employed

Unemployed

Social Security Benefits

Spouse's 2023 Estimated Annual Income * If Any

$

Will you be filing taxes jointly with your spouse for 2023? *

Yes

No

Personal 2023 Employment

Employed

Unemployed

Receiving Social Security

Employer Name *

Estimated 2023 Annual Income *

$

Does your employer offer you insurance? *

Yes

No

SS Income Amount *

$

How often do you get this amount? *

Do you currently have Medicare? *

Yes

No

What is your estimated total annual income for 2023?

$

*

If making less than $1700/mo, I agree I am looking for a job making minimum wage or better

Will you claim any dependents on your taxes? *

Yes

No

Please provide this information even if your dependents do not need coverage

Dependent 1 *

Full Name
Date of Birth
SSN
Gender

Dependent 1 Coverage (Please Select One) *

Yes, add this this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 2 *

Full Name
Date of Birth
SSN
Gender

Dependent 2 Coverage (Please Select One) *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 3 *

Full Name
Date of Birth
SSN
Gender

Dependent 3 Coverage (Please Select One) *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 4 *

Full Name
Date of Birth
SSN
Gender

Dependent 4 Coverage (Please Select One) *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 5 *

Full Name
Date of Birth
SSN
Gender

Dependent 5 Coverage (Please Select One) *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent 6 *

Full Name
Date of Birth
SSN
Gender

Dependent 6 Coverage (Please Select One) *

Yes, add this dependent to the policy

No, this dependent does not need coverage

Add another dependent? *

Yes

No

Dependent Names & Gender (press enter after each gender) *

Dependent Birthdays (press enter after each DOB) *

Dependent SSNs (press enter after each SSN) *

Do all of these dependents need covered on this policy? *

Yes

No

Do you have currently have Health Insurance Coverage? *

Yes

No

What kind of insurance do you have? *

Medicare Card Number *

Part A Effective Date

Part B Effective Date

Do you have a Primary Care Doctor you see regularly? *

Yes

No

Primary Care Doctor's Full Name *

What city are they in? *

Do have any specialist you see? *

Yes

No

Please list all Specialist Names and Cities (press enter to after each for multiple) *

Do you take any prescription medicine? *

Yes

No

Please list all prescription medicine you take: *

Preferred Pharmacy

Your Social Security Number *

Confirmation *

By checking this box, you attest that all of the information is true and correct to the best of your knowledge. You are giving Fruitful Financial the permission to finish processing your Health Insurance Marketplace application. You also agree to Fruitful Financial becoming your Agent of Record with your health insurance provider through the Health Insurance Marketplace. You understand that Fruitful Financial will be your agent of record on your health insurance policy unless you email support@fruitfulfinancial.com and put your name, date of birth and a written request that you wish to use a different agent. You agree to receive recurring automated promotional and personalized marketing text (e.g., SMS and MMS) messages (e.g. event reminders) from Fruitful Financial, LLC including text messages that may be sent using an automatic telephone dialing system, to the mobile telephone number you provided when signing up or any other number that you designate. Consent to receive automated marketing text messages is not a condition of any purchase. Msg & Data rates may apply. You can Reply STOP to opt out.

Signature *

Clear

DON't PASS on free money

Fruitful Financial is an insurance broker that connects individuals with insurance providers. Products and services are provided exclusively by the providers. Descriptions are for informational purposes only and subject to change. Insurance plans may not be available in all states. By submitting your phone number, you are giving Fruitful Financial permission to communicate with you via automatically-sent text message.