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Zip Code *

First Name *

Last Name *

Email *

Phone *

I consent to have a representative from GoVine Insurance contact me at the number I provided. I understand these calls may be generated using an automated dialer and that my consent is not required as a precondition for purchasing or receiving any property, goods or service.

What is your address where we can mail the insurance cards?

Address *

City *

State *

County *

Your Date of Birth *

Are you a US Citizen? *

Yes

No

Primary Applicant's Social Security Number *

Who is your most recent employer? *

What is your estimated income this year? *

$

This is your income before taxes.

Do you have a spouse? *

Yes

No

Spouse's Date of Birth MM/DD/YYYY *

Spouse Legal First Name *

Spouse Legal Last Name *

When Filing Taxes do you file? *

Jointly

Separately

Do you want to enroll your spouse? *

Yes

No

Do you have tax dependents? *

Yes

No

Dependent 1 Full Legal Name *

Dependent 1 Date of Birth MM-DD-YYYY *

Does your dependent have Medicaid or CHIP? *

Yes

No

Does your dependent need coverage? *

Yes

No

Do You Have a 2nd Dependent? *

Yes

No

Dependent 2 Full Legal Name *

Dependent 2 Date of Birth MM-DD-YYYY *

Does your dependent have Medicaid or CHIP? *

Yes

No

Does your dependent need coverage? *

Yes

No

Do You Have a 3rd Dependent? *

Yes

No

Dependent 3 Full Legal Name *

Dependent 3 Date of Birth MM-DD-YYYY *

Does your dependent have Medicaid or CHIP? *

Yes

No

Does your dependent need coverage? *

Yes

No

Do You Have a 4th Dependent? *

Yes

No

Dependent 4 Full Legal Name *

Dependent 4 Date of Birth MM-DD-YYYY *

Does your dependent have Medicaid or CHIP? *

Yes

No

Does your dependent need coverage? *

Yes

No

Do You Have a 5th Dependent? *

Yes

No

Dependent 5 Full Legal Name *

Dependent 5 Date of Birth MM-DD-YYYY *

Does your dependent have Medicaid or CHIP? *

Yes

No

Does your dependent need coverage? *

Yes

No

Do you currently have a Marketplace Plan? *

Yes

No

By signing below, you agree to the following attestations:

Authorization Date *

Authorization Signature *

Clear

YOUR INFORMATION IS 100% SECURE

Terms of Service

By using our services, you agree to the following terms:

Representation: You grant the authorized agent, as mentioned in the attestation disclaimer, the authority to act on your behalf concerning health insurance matters, including enrollment, renewals, and related decisions.

Accuracy: You confirm that all information provided is true and accurate. False or misleading information can lead to the termination of services.

Revocation: Your consent remains in effect until you revoke it. You may revoke or modify your consent at any time.

Limitation of Liability: The authorized agent and associated entities are not liable for any errors or omissions in the services provided or for any damages, including indirect or consequential damages.

Privacy Policy

Data Collection: Our Agents collect Personally Identifiable Information (PII) solely for the purposes mentioned in our Comprehensive Attestation Agreement.

Data Protection: We are committed to ensuring the privacy and safety of your PII. Your data will not be shared for any purposes other than those explicitly stated in our agreement.

Income Attestation: We use your income information solely to determine eligibility for health insurance programs and potential subsidies.

TCPA Disclaimer: By providing your phone number, you expressly consent to receive auto-dialed and/or pre-recorded telemarketing calls, text messages, and/or emails from the authorized agent mentioned in the attestation disclaimer at the phone number and email address you provided, including for marketing purposes. You understand that consent is not a condition of purchase. Message and data rates may apply.