Health Insurance - PhoneOps Funding, LLC

Your first & last name:

Contact number:

Email address:

Language:

Full address including 1. City, 2. County, 3. State, 4. Zip & 5. Country:

State & Country where you were born:

Date of birth:

Gender:

Marital Status:

Married file jointly

Married file seperately

Not Married

Which of the following do you have?

Social Security Card

Green Card

VISA

Social Security Number:

Green Card or VISA Number: (Put N/A if none)

Choose a Security Code question:

What's your favorite pet?

What's your favorite color?

What's your favorite food?

Put the answer to your Security Code question:

Employment Status:

Work - W2

Work - 1099

Own a Business

Don't work

I get SSI

Current or previous job title:

Monthly income:

If I currently do not have employment or would like a another source of income, I will go to: https://www.BlockCallsNow.com/Careers to apply for employment to become an Executive Hiring Manager. I agree to file my taxes in 2023 and claim my new job as an Executive Hiring Manager on my taxes.

(SKIP THIS PAGE IF NO SPOUSE) - Spouse first & last name:

Contact number:

Email address:

Social Security Number: (Put N/A if none)

Green Card or VISA Number: (Put N/A if none)

Date of Birth:

Monthly income:

Current or previous job title:

(SKIP THIS PAGE IF NO DEPENDENTS) - Dependent 1 - Enter the following: 1. First & Last name. 2. Date of Birth. 3. Social Security Number. 4. Gender. 5. Monthly Income:

Dependent 2 - Enter the following: 1. First & Last name. 2. Date of Birth. 3. Social Security Number. 4. Gender. 5. Monthly Income:

Dependent 3 - Enter the following: 1. First & Last name. 2. Date of Birth. 3. Social Security Number. 4. Gender. 5. Monthly Income:

Dependent 4 - Enter the following: 1. First & Last name. 2. Date of Birth. 3. Social Security Number. 4. Gender. 5. Monthly Income:

Dependent 5 - Enter the following: 1. First & Last name. 2. Date of Birth. 3. Social Security Number. 4. Gender. 5. Monthly Income:

This application is a quote for the $0.00 a Month Starter Plan through the Affordable Care Act and your household income, date of birth and zip code will determine what you qualify for. Do you understand?

Yes

Outside this Government Program, do you need anything else?

Yes, Dental Only

Yes, Vision Only

Yes, Dental & Vision

Life Insurance Only

Life & Dental

Comments, Concerns & Additional Information: (If none, put N/A)

Insurance Assistant's Full Name:

3 + 3 =

This is a secured site. All information is confidential!

When uploading the required documents, make sure the name of the document doesn’t have any spaces. Example: your State ID, make sure you save it as StateID, no spaces.

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