AgentRomulus Health Insurance Enrollment Form
Meet Agent Romulus: The People's Lover!

Are you looking for someone who's got your back when it comes to insurance? Look no further! Agent Romulus brings 14 years of experience and a passion for helping you get more coverage while saving you more money. Your peace of mind is our priority! Give me 10 minute of your time and let me show you how you may qualify for $0 Monthly Premium- $0 Enrollment Fee & GET COVERAGE FROM THE NAMES YOU TRUST. FILL OUT THE FORM BELOW 
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First Name *
Last Name *
Date Of Birth *
Gender *
Mobile Phone *
E-mail *
Current Address  *
City *
County *
State *
Zip Code *
Marital Status *
Height *
Weight *
Primary Doctors Name, Phone Number & Address *
Are you currently on Medicare *
Do you Smoke ? *
Are you a U.S Citizen Or Permanent Resident  *
SSN OR TAX ID #
Employer Info  *
Do you have any of the following health conditions ? *
Required
How many people in your household  *
What is your expected 2023 annual household income ? *
Have you had a qualifying life event in the past 60 days.  *
PROVIDE NAMES OF ANY FAMILY MEMBER OR FRIENDS THAT NEEDS HELP WITH HEALTH INSURANCE. 
I, give my permission to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above mention agent to view and use the confidential information provided by me in writing , electronically, or by telephone only for the purpose of one or more of the following: Searching for an existing Marketplace application ; Completing an application for eligibility and enrollment in a Marketplace Qualified Health plan or other government insurance affordability programs, such as medicaid and chip or advance tax credits to help pay for the Marketplace premiums; Providing ongoing account maintenance and enrollment assistance, for renewal i would like my current policy to remain in effect unless the plan is no longer available at which time i would like to be renewed into a similar plan as necessary; or Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that i do not have to share additional personal information about myself or my health with my agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by calling or texting 754-368-9751 or emailing my agent at AgentRomulus@gmail.com.  

Please provide full name of the person filling out this form and agreeing to the terms and conditions. 
*
Electronic Signature  *
You accept the terms and Conditions of this form *
Agent Romulus I am here to help. 
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