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Omnicore Health

Self - Enrollment

Name

Birthday

Gender

Phone

Email Address

Address

City

State

Zip

User Identification

Are You a U.S. Citizen

Drivers License: Front

Drivers License: Back

SSN

Household Income

Employer Info

Job Title

Company Name

Expected Annual Income This Year

Additional Information

Are you a smoker?

Is anyone applying for health coverage on this application CURRENTLY incarcerated
(detained or jailed)?

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

I know that I must tell the program I'll be enrolled in if the information I listed on this application changes. I know I can make changes in my Marketplace account or by calling (888) 244 -1129 I understand that a change in my information could affect my eligibility for member(s) of my household.

What are the most important benefits to you in your health insurance policy?

Do You Have Health Insurance?

Marital Status

Dependents?

Spouse Details

Gender

Birthday

Dependent #1 Details

Gender

Birthday

Dependent #2 Details

Gender

Birthday

Dependent #3 Details

Gender

Birthday

In Addition To Healthcare Which Insurance Would You Like ?

Digital Consent Agreement

Do you authorize Omnicore Health to submit your Application to the Marketplace for your $0 per month health plan?

Do you authorize Omnicore Health to update and make changes to your health plan, in order to keep your policy active or prevent you from losing coverage if needed?

Do you authorize Omnicore Health to call, text, or email you when we need to update your policy and assist with documents the marketplace may require, such as your income letter?

If the current plan you’re enrolling in today is not available at a $0 cost for the following years, do you authorize Omnicore Health to enroll you in the next best $0 health plan with the same or similar insurance provider that you are enrolling in today?

Do you give consent and Authorize Omnicore Health to select and or choose a plan on behalf of the customer enrolling in this application?

Notes Or Additional Dependents

Referred By

Your Signature

By clicking ENROLL NOW, you consent and request to be enrolled by Omnicore Health Benefits Agency, LLC (dba omnicore health insurance agency), and their agents, they may contact you by phone, email and text/SMS to your home or mobile number(s) you provided, even if you provided a number that is registered on a National, State, or Private Do Not Call List.

You agree to receive automated Promotional and Transactional SMS.

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Omnicore Health is a team of skilled health insurance professionals who utilize cutting-edge digital technologies and provide a premium concierge experience to greatly simplify the health insurance enrollment process.

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Omnicore Health

Self - Enrollment

User Identification

Household Income

Additional Information

Spouse Details

Dependent #1 Details

Dependent #2 Details

Dependent #3 Details

Digital Consent Agreement

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