AFFORDABLE AMERICAN

HEALTH CARE

AFFORDABLE AMERICAN

HEALTH CARE

Get NEW Subsidized MarketPlace

ObamaCare Now!

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications.

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

First Name *

Last Name *

Phone *

Email *

Date of birth

Male or Female

Have you used tobacco 4 or more times a week for the past 6 months?

YES

Address *

City *

State *

Country

Afghanistan
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Benin
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Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
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Senegal
Serbia
Seychelles
Sierra Leone
Singapore
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Slovenia
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Somalia
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Spain
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Sudan
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Eswatini
Sweden
Switzerland
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Tajikistan
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Thailand
Timor-Leste
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Ukraine
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Virgin Islands, U.S.
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Zimbabwe
No elements found. Consider changing the search query.
List is empty.

Postal code *

Marital Status *

Single

Married

Divorced

Widowed

Spouse's Name

Spouse's DOB

Has your spouse used tobacco 4 or more times a week for the past 6 months?

Yes

Spouse's Employment

Employed

Self-Employed

Social Security Benefits

Unemployed

Spouse's Estimated Monthly Income*

PLEASE INCLUDE EVEN IF YOU DO NOT WANT THEM ON YOUR HEALTH INSURANCE POLICY

Do you want your spouse covered on this policy?

Yes

Spouse's Social Security #?

Your Employment Information *

Employed

Unemployed

Receiving Social Security

Employer Name

Estimated Monthly Income

SSI Monthly Income *

Are you claiming any dependents on your taxes?

Yes

Child's Full Name *

Child's DOB *

Child's SSN *

if there are multiple dependents, please list additional information here

Doctor's Full Name

Doctor's City

In Order to get a Cost Sharing Reduction and an Advanced Premium Tax Credit you will need to file a tax return for the upcoming year. Will you file a tax return for the coming year?

Yes

What is your social security #? *

Agent/Broker Consent *

By Clicking this box,I give my permission to Johnny Woo NPN 18447961 and/or Zaneta Woo NPN 20545090 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-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes 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 Marketplace premiums; Providing ongoing account maintenance and enrollment assistance, as necessary; or Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the Johnny Woo NPN 18447961 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 contacting Johnny Woo NPN 18447961 at anytime. You also attest that all of the information is true and correct to the best of your knowledge. You are also giving Johnny Woo NPN 18447961 the permission to process your application with the information given to us.

As per CMS guidelines please acknowledge that you give me, JOHNNY WOO and/or ZANETA WOO and agency owner, “DANIEL VILLA” of “FIDES INS.” and the agents affiliated with our agency to work on your behalf in the Marketplace. Search and compare all Marketplace plans for you Review your current application and update income/household info if needed Enroll you in the plan that gives you the lowest monthly payment and best coverage For future years: Send you renewal options every Open Enrollment Automatically re-enroll you in the same or better plan if we don’t hear back from you within 14 days of our renewal notice Switch you to a more affordable plan if your current premium increases more than 10% (we will always notify you first) You are confirming that all information on your application is true and accurate to the best of your knowledge. You can cancel this authorization anytime by texting (813)-686-7438 STOP or emailing fortressinsgrp@gmail.com

Signature *

Clear

ObamaCare Now!

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications. One of our Marketplace Specialists will Process your application to get you the best coverage possible

First Name *

Last Name *

Phone *

Email *

Date of birth

Male or Female

Have you used tobacco 4 or more times a week for the past 6 months?

YES

Address *

City *

State *

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
No elements found. Consider changing the search query.
List is empty.

Postal code *

Marital Status *

Single

Married

Divorced

Widowed

Spouse's Name

Spouse's DOB

Has your spouse used tobacco 4 or more times a week for the past 6 months?

Yes

Spouse's Employment

Employed

Self-Employed

Social Security Benefits

Unemployed

Spouse's Estimated Monthly Income*

PLEASE INCLUDE EVEN IF YOU DO NOT WANT THEM ON YOUR HEALTH INSURANCE POLICY

Do you want your spouse covered on this policy?

Yes

Spouse's Social Security #?

Your Employment Information *

Employed

Unemployed

Receiving Social Security

Employer Name

Estimated Monthly Income

SSI Monthly Income *

Are you claiming any dependents on your taxes?

Yes

Child's Full Name *

Child's DOB *

Child's SSN *

if there are multiple dependents, please list additional information here

Doctor's Full Name

Doctor's City

In Order to get a Cost Sharing Reduction and an Advanced Premium Tax Credit you will need to file a tax return for the upcoming year. Will you file a tax return for the coming year?

Yes

What is your social security #? *

Agent/Broker Consent *

Signature *

Clear

AFFORDABLE AMERICAN

HEALTH CARE

AFFORDABLE AMERICAN

HEALTH CARE

Get NEW Subsidized MarketPlace

ObamaCare Now!

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications.

Get NEW Subsidized MarketPlace

ObamaCare Now!

No need to have your phone ringing off the hook with Salesman, Or complete confusing on-line Applications. One of our Marketplace Specialists will Process your application to get you the best coverage possible

All Rights Reserved - 2022

All Rights Reserved - 2022