RTHQ Health Application

Date

Application Status

Please don't touch this when filling out the form; this is just for use internally after the initial form is saved. Thank you!

Agent & Plan Info

Submitting Agent Name*

Plan Name*

Expected Premium*

Carrier*

Master General Agent / NPN*

Please select an option based on carrier and state:

Mark MacFawn, 8997756 = Everything EXCEPT for BCBS of SC, BCBS of FL, & FHCP of FL

Constantine Christoforakis, 17328248 = BCBS of SC

Mark Whiffen, 13119046 = BCBS of FL & FHCP of FL

Mark MacFawn, 8997756
Constantine Christoforakis, 17328248
Mark Whiffen, 13119046

Applicant Info

Primary Applicant Information*

First Name Last Name Suffix

Applying for Coverage?*

Home Address*

Street Address Address Line 2 City State ZIP Code

County*

Mailing address differs from home address.

Alternate Mailing Address

Street Address Address Line 2 City State ZIP Code

County*

Email Address*

Phone Number*

Contact Preference

Gender*

Date of Birth*

Social Security Number*

Annual Income*

Estimates are okay.

Income Source*

Employer Name*

Employer Phone Number*

Additional Sources of Income

If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.

How do you plan to file taxes for 2016?*

Check all that apply:

US Citizen
Married
Parent/Caretaker
Tobacco User
Full-time Student
Eligible for insurance through an employer (including a family member's employer) or COBRA?
Currently enrolled in an individual health plan (not from an employer)
Currently enrolled in Medicare

Born in the US?

Yes
No

Do you have any of the following?

Certification of Naturalization or Citizenship
Permanent Resident Card
Employment Authorization Card
Certificate of Non-Immigrant F-1 or I-20 (for students)
Machine Readable Immigrant Visa w/ Temporary I-551 language
Temporary Stamp I-551 on Passport or I-94, I-94A
Arrival/Departure Record onト94,I94A
Arrival/Departure Record in Foreign Passport

Certification of Naturalization or Citizenship

Certificate Number	Registration Number	Full Exact Name	Issue Date

Permanent Resident Card

Alien Number (A#)	Card # (Optional)

Employment Authorization Card

Alien Number (A#)	Card # (Optional)	Expiration Date (Optional)	Category Code (Optional)

Certificate of Non-Immigrant F-1 or I-20 (for students)

SEVIS ID #

Machine Readable Immigrant Visa w/ Temporary I-551 Language

Alien Number (A#)	Passport #	Country of Issuance

Temporary Stamp I-551 on Passport or I-94,I-94A

Alien Number (A#)

Arrival/Departure Record onト94,I94A

I-94 #	SEVIS ID #

Arrival/Departure Record in Foreign Passport

I-94 #	Passport #	Expiration Date	Country of Issuance	SEVIS ID # (Optional)

Household Size*

Please tell us about all members of your household, including those that are not applying for coverage. Your household is defined as the people on the same tax return as you.

# Applying for Coverage*

Applicant #2*

First Name Last Name Suffix

Applicant #2 - Applying for Coverage?*

Application #2 - Gender*

Applicant #2 - Date of Birth*

Applicant #2 - Social Security Number*

Applicant #2 - Annual Income*

Estimates are okay.

Applicant #2 - Income Source*

Applicant #2 - Employer Name*

Applicant #2 - Employer Phone Number*

Applicant #2 - Additional Sources of Income

If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.

Applicant #2 - Check all that apply:

US Citizen
Married
Parent/Caretaker
Tobacco User
Full-time Student
Eligible for insurance through an employer (including a family member's employer) or COBRA?
Currently enrolled in an individual health plan (not from an employer)
Currently enrolled in Medicare

Applicant #2 - Born in the US?

Yes
No

Applicant #2 - Do you have any of the following?

Certification of Naturalization or Citizenship
Permanent Resident Card
Employment Authorization Card
Certificate of Non-Immigrant F-1 or I-20 (for students)
Machine Readable Immigrant Visa w/ Temporary I-551 language
Temporary Stamp I-551 on Passport or I-94, I-94A
Arrival/Departure Record onト94,I94A
Arrival/Departure Record in Foreign Passport

Applicant #2 - Certification of Naturalization or Citizenship

Certificate Number	Registration Number	Full Exact Name	Issue Date

Applicant #2 - Permanent Resident Card

Alien Number (A#)	Card # (Optional)

Applicant #2 - Employment Authorization Card

Alien Number (A#)	Card # (Optional)	Expiration Date (Optional)	Category Code (Optional)

Applicant #2 - Certificate of Non-Immigrant F-1 or I-20 (for students)

SEVIS ID #

Applicant #2 - Machine Readable Immigrant Visa w/ Temporary I-551 Language

Alien Number (A#)	Passport #	Country of Issuance

Applicant #2 - Temporary Stamp I-551 on Passport or I-94,I-94A

Alien Number (A#)

Applicant #2 - Arrival/Departure Record onト94,I94A

I-94 #	SEVIS ID #

Applicant #2 - Arrival/Departure Record in Foreign Passport

I-94 #	Passport #	Expiration Date	Country of Issuance	SEVIS ID # (Optional)

Applicant #3*

First Name Last Name Suffix

Applicant #3 - Applying for Coverage?*

Application #3 - Gender*

Applicant #3 - Date of Birth*

Applicant #3 - Social Security Number*

Applicant #3 - Annual Income*

Estimates are okay.

Applicant #3 - Income Source*

Applicant #3 - Employer Name*

Applicant #3 - Employer Phone Number*

Applicant #3 - Additional Sources of Income

If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.

Applicant #3 - Check all that apply:

US Citizen
Married
Parent/Caretaker
Tobacco User
Full-time Student
Eligible for insurance through an employer (including a family member's employer) or COBRA?
Currently enrolled in an individual health plan (not from an employer)
Currently enrolled in Medicare

Applicant #3 - Born in the US?

Yes
No

Applicant #3 - Do you have any of the following?

Certification of Naturalization or Citizenship
Permanent Resident Card
Employment Authorization Card
Certificate of Non-Immigrant F-1 or I-20 (for students)
Machine Readable Immigrant Visa w/ Temporary I-551 language
Temporary Stamp I-551 on Passport or I-94, I-94A
Arrival/Departure Record onト94,I94A
Arrival/Departure Record in Foreign Passport

Applicant #3 - Certification of Naturalization or Citizenship

Certificate Number	Registration Number	Full Exact Name	Issue Date

Applicant #3 - Permanent Resident Card

Alien Number (A#)	Card # (Optional)

Applicant #3 - Employment Authorization Card

Alien Number (A#)	Card # (Optional)	Expiration Date (Optional)	Category Code (Optional)

Applicant #3 - Certificate of Non-Immigrant F-1 or I-20 (for students)

SEVIS ID #

Applicant #3 - Machine Readable Immigrant Visa w/ Temporary I-551 Language

Alien Number (A#)	Passport #	Country of Issuance

Applicant #3 - Temporary Stamp I-551 on Passport or I-94,I-94A

Alien Number (A#)

Applicant #3 - Arrival/Departure Record onト94,I94A

I-94 #	SEVIS ID #

Applicant #3 - Arrival/Departure Record in Foreign Passport

I-94 #	Passport #	Expiration Date	Country of Issuance	SEVIS ID # (Optional)

Applicant #4*

First Name Last Name Suffix

Applicant #4 - Applying for Coverage?*

Application #4 - Gender*

Applicant #4 - Date of Birth*

Applicant #4 - Social Security Number*

Applicant #4 - Annual Income*

Estimates are okay.

Applicant #4 - Income Source*

Applicant #4 - Employer Name*

Applicant #4 - Employer Phone Number*

Applicant #4 - Additional Sources of Income

If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.

Applicant #4 - Check all that apply:

US Citizen
Married
Parent/Caretaker
Tobacco User
Full-time Student
Eligible for insurance through an employer (including a family member's employer) or COBRA?
Currently enrolled in an individual health plan (not from an employer)
Currently enrolled in Medicare

Applicant #4 - Born in the US?

Yes
No

Applicant #4 - Do you have any of the following?

Certification of Naturalization or Citizenship
Permanent Resident Card
Employment Authorization Card
Certificate of Non-Immigrant F-1 or I-20 (for students)
Machine Readable Immigrant Visa w/ Temporary I-551 language
Temporary Stamp I-551 on Passport or I-94, I-94A
Arrival/Departure Record onト94,I94A
Arrival/Departure Record in Foreign Passport

Applicant #4 - Certification of Naturalization or Citizenship

Certificate Number	Registration Number	Full Exact Name	Issue Date

Applicant #4 - Permanent Resident Card

Alien Number (A#)	Card # (Optional)

Applicant #4 - Employment Authorization Card

Alien Number (A#)	Card # (Optional)	Expiration Date (Optional)	Category Code (Optional)

Applicant #4 - Certificate of Non-Immigrant F-1 or I-20 (for students)

SEVIS ID #

Applicant #4 - Machine Readable Immigrant Visa w/ Temporary I-551 Language

Alien Number (A#)	Passport #	Country of Issuance

Applicant #4 - Temporary Stamp I-551 on Passport or I-94,I-94A

Alien Number (A#)

Applicant #4 - Arrival/Departure Record onト94,I94A

I-94 #	SEVIS ID #

Applicant #4 - Arrival/Departure Record in Foreign Passport

I-94 #	Passport #	Expiration Date	Country of Issuance	SEVIS ID # (Optional)

Applicant #5*

First Name Last Name Suffix

Applicant #5 - Applying for Coverage?*

Application #5 - Gender*

Applicant #5 - Date of Birth*

Applicant #5 - Social Security Number*

Applicant #5 - Annual Income*

Estimates are okay.

Applicant #5 - Income Source*

Applicant #5 - Employer Name*

Applicant #5 - Employer Phone Number*

Applicant #5 - Additional Sources of Income

If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.

Applicant #5 - Check all that apply:

US Citizen
Married
Parent/Caretaker
Tobacco User
Full-time Student
Eligible for insurance through an employer (including a family member's employer) or COBRA?
Currently enrolled in an individual health plan (not from an employer)
Currently enrolled in Medicare

Applicant #5 - Born in the US?

Yes
No

Applicant #5 - Do you have any of the following?

Certification of Naturalization or Citizenship
Permanent Resident Card
Employment Authorization Card
Certificate of Non-Immigrant F-1 or I-20 (for students)
Machine Readable Immigrant Visa w/ Temporary I-551 language
Temporary Stamp I-551 on Passport or I-94, I-94A
Arrival/Departure Record onト94,I94A
Arrival/Departure Record in Foreign Passport

Applicant #5 - Certification of Naturalization or Citizenship

Certificate Number	Registration Number	Full Exact Name	Issue Date

Applicant #5 - Permanent Resident Card

Alien Number (A#)	Card # (Optional)

Applicant #5 - Employment Authorization Card

Alien Number (A#)	Card # (Optional)	Expiration Date (Optional)	Category Code (Optional)

Applicant #5 - Certificate of Non-Immigrant F-1 or I-20 (for students)

SEVIS ID #

Applicant #5 - Machine Readable Immigrant Visa w/ Temporary I-551 Language

Alien Number (A#)	Passport #	Country of Issuance

Applicant #5 - Temporary Stamp I-551 on Passport or I-94,I-94A

Alien Number (A#)

Applicant #5 - Arrival/Departure Record onト94,I94A

I-94 #	SEVIS ID #

Applicant #5 - Arrival/Departure Record in Foreign Passport

I-94 #	Passport #	Expiration Date	Country of Issuance	SEVIS ID # (Optional)

Applicant #6*

First Name Last Name Suffix

Applicant #6 - Applying for Coverage?*

Application #6 - Gender*

Applicant #6 - Date of Birth*

Applicant #6 - Social Security Number*

Applicant #6 - Annual Income*

Estimates are okay.

Applicant #6 - Income Source*

Applicant #6 - Employer Name*

Applicant #6 - Employer Phone Number*

Applicant #6 - Additional Sources of Income

If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.

Applicant #6 - Check all that apply:

US Citizen
Married
Parent/Caretaker
Tobacco User
Full-time Student
Eligible for insurance through an employer (including a family member's employer) or COBRA?
Currently enrolled in an individual health plan (not from an employer)
Currently enrolled in Medicare

Applicant #6 - Born in the US?

Yes
No

Applicant #6 - Do you have any of the following?

Certification of Naturalization or Citizenship
Permanent Resident Card
Employment Authorization Card
Certificate of Non-Immigrant F-1 or I-20 (for students)
Machine Readable Immigrant Visa w/ Temporary I-551 language
Temporary Stamp I-551 on Passport or I-94, I-94A
Arrival/Departure Record onト94,I94A
Arrival/Departure Record in Foreign Passport

Applicant #6 - Certification of Naturalization or Citizenship

Certificate Number	Registration Number	Full Exact Name	Issue Date

Applicant #6 - Permanent Resident Card

Alien Number (A#)	Card # (Optional)

Applicant #6 - Employment Authorization Card

Alien Number (A#)	Card # (Optional)	Expiration Date (Optional)	Category Code (Optional)

Applicant #6 - Certificate of Non-Immigrant F-1 or I-20 (for students)

SEVIS ID #

Applicant #6 - Machine Readable Immigrant Visa w/ Temporary I-551 Language

Alien Number (A#)	Passport #	Country of Issuance

Applicant #6 - Temporary Stamp I-551 on Passport or I-94,I-94A

Alien Number (A#)

Applicant #6 - Arrival/Departure Record onト94,I94A

I-94 #	SEVIS ID #

Applicant #6 - Arrival/Departure Record in Foreign Passport

I-94 #	Passport #	Expiration Date	Country of Issuance	SEVIS ID # (Optional)

Applicant #7*

First Name Last Name Suffix

Applicant #7 - Applying for Coverage?*

Application #7 - Gender*

Applicant #7 - Date of Birth*

Applicant #7 - Social Security Number*

Applicant #7 - Annual Income*

Estimates are okay.

Applicant #7 - Income Source*

Applicant #7 - Employer Name*

Applicant #7 - Employer Phone Number*

Applicant #7 - Additional Sources of Income

If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.

Applicant #7 - Check all that apply:

US Citizen
Married
Parent/Caretaker
Tobacco User
Full-time Student
Eligible for insurance through an employer (including a family member's employer) or COBRA?
Currently enrolled in an individual health plan (not from an employer)
Currently enrolled in Medicare

Applicant #7 - Born in the US?

Yes
No

Applicant #7 - Do you have any of the following?

Certification of Naturalization or Citizenship
Permanent Resident Card
Employment Authorization Card
Certificate of Non-Immigrant F-1 or I-20 (for students)
Machine Readable Immigrant Visa w/ Temporary I-551 language
Temporary Stamp I-551 on Passport or I-94, I-94A
Arrival/Departure Record onト94,I94A
Arrival/Departure Record in Foreign Passport

Applicant #7 - Certification of Naturalization or Citizenship

Certificate Number	Registration Number	Full Exact Name	Issue Date

Applicant #7 - Permanent Resident Card

Alien Number (A#)	Card # (Optional)

Applicant #7 - Employment Authorization Card

Alien Number (A#)	Card # (Optional)	Expiration Date (Optional)	Category Code (Optional)

Applicant #7 - Certificate of Non-Immigrant F-1 or I-20 (for students)

SEVIS ID #

Applicant #7 - Machine Readable Immigrant Visa w/ Temporary I-551 Language

Alien Number (A#)	Passport #	Country of Issuance

Applicant #7 - Temporary Stamp I-551 on Passport or I-94,I-94A

Alien Number (A#)

Applicant #7 - Arrival/Departure Record onト94,I94A

I-94 #	SEVIS ID #

Applicant #7 - Arrival/Departure Record in Foreign Passport

I-94 #	Passport #	Expiration Date	Country of Issuance	SEVIS ID # (Optional)

Applicant #8*

First Name Last Name Suffix

Applicant #8 - Applying for Coverage?*

Application #8 - Gender*

Applicant #8 - Date of Birth*

Applicant #8 - Social Security Number*

Applicant #8 - Annual Income*

Estimates are okay.

Applicant #8 - Income Source*

Applicant #8 - Employer Name*

Applicant #8 - Employer Phone Number*

Applicant #8 - Additional Sources of Income

If applicable, please add any ADDITIONAL sources of income, complete with phone number and any other relevant information.

Applicant #8 - Check all that apply:

US Citizen
Married
Parent/Caretaker
Tobacco User
Full-time Student
Eligible for insurance through an employer (including a family member's employer) or COBRA?
Currently enrolled in an individual health plan (not from an employer)
Currently enrolled in Medicare

Applicant #8 - Born in the US?

Yes
No

Applicant #8 - Do you have any of the following?

Certification of Naturalization or Citizenship
Permanent Resident Card
Employment Authorization Card
Certificate of Non-Immigrant F-1 or I-20 (for students)
Machine Readable Immigrant Visa w/ Temporary I-551 language
Temporary Stamp I-551 on Passport or I-94, I-94A
Arrival/Departure Record onト94,I94A
Arrival/Departure Record in Foreign Passport

Applicant #8 - Certification of Naturalization or Citizenship

Certificate Number	Registration Number	Full Exact Name	Issue Date

Applicant #8 - Permanent Resident Card

Alien Number (A#)	Card # (Optional)

Applicant #8 - Employment Authorization Card

Alien Number (A#)	Card # (Optional)	Expiration Date (Optional)	Category Code (Optional)

Applicant #8 - Certificate of Non-Immigrant F-1 or I-20 (for students)

SEVIS ID #

Applicant #8 - Machine Readable Immigrant Visa w/ Temporary I-551 Language

Alien Number (A#)	Passport #	Country of Issuance

Applicant #8 - Temporary Stamp I-551 on Passport or I-94,I-94A

Alien Number (A#)

Applicant #8 - Arrival/Departure Record onト94,I94A

I-94 #	SEVIS ID #

Applicant #8 - Arrival/Departure Record in Foreign Passport

I-94 #	Passport #	Expiration Date	Country of Issuance	SEVIS ID # (Optional)

Authorizations

1. No one applying for coverage is in jail.

2. I give permission to the federal marketplace to access my tax returns years to verify my income for subsidy purposes. I can revoke this permission at anytime.

3. I will notify the insurer if anything on this application changes. I can do this through the federal marketplace. I understand a change could affect out eligibility for plans and subsidies.

4. I’m electronically signing this application, which means I’ve provided true answers to all of the questions to the best of my knowledge.

5. I authorize (Your Name) to submit and sign this application on my behalf.

Notes

Please add any notes or other additional information here.

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