Affordable Health Insurance Call Us Today To Speak With An Agent (877) 324 – 3475 Comprehensive Coverage & Nationwide Confidence Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Wellthy Communities Inc First Name *Last Name *Date of Birth *Gender *MaleFemalePhone *Email *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code *Are you a U.S. Citizen *YesNoSSN *Employer Info *JobSelf-EmployedUnemployment BenefitsSocial SecurityOtherExpected Annual 2025 Income USD $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.AgreeDisagreeI 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 (877) 324 - 3475. I understand that a change in my information could affect my eligibility for member(s) of my household.AgreeDisagreeWhat are the most importnat benefits to you in your Health insurance policy?PrescriptionsDr. VisitsSpecialistOtherNo PreferenceDo you have health insurance?YesNoPlease select the health insurance carrier you prefer?CareFirst (BCBS)KaiserUnitedHealthMarital StatusSingleMarriedSingle withDependentsMarried with DependentsDependents *NoYesSpouseFirstLastSpouse GenderMaleFemaleSpouse Date of BirthDependent 1FirstLastGender 1MaleFemaleDate of Birth 1Dependent 2FirstLastGender 2MaleFemale when in Dependent Date of Birth 2Dependent 3FirstLastGender 3MaleFemaleDate of Birth 3In addition to healthcare which insurance would you like ?DentalVisionLife InsuranceDo you authorize Every Health to submit your Application to the Marketplace for your monthly health plan?YesNoDo you authorize Every 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? YesNoDo you authorize Every 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?YesNoIf the current plan you’re enrolling in today is not available at a $0 cost for the following years, do you authorize Every Health to enroll you in the next best $0 health plan with the same or similar insurance provider that you are enrolling in today?YesNoDo you give consent and Authorize Every Health Group to select and or choose a plan on behalf of the customer enrolling in this application?YesNoNotes Or Additional DependentsReferral NameSignature Clear Signature Final Steps: Click Submit. Create an Account "Maryland Health" Verify Email. Click on Find Assistance. Type Sharma Saintval "search". Confirm Saintval as your agent. Agent will follow up within 24 hrs. Submit