Dependable Coverage

Fill Out the form below to get started!

First Name

Last Name

I attest that I qualify for one of the following Special Enrollment Periods

I am losing coverage before the end of the current month

I have lost coverage within the last 60 days

I was denied Medicaid by my state

I recently moved to a new county or state

Address

City

State

Zip code

Phone

Email

Date of Birth *

Gender

(Social Security Number: OPTIONAL but if you don’t include it on our application you will need to send in proof of citizenship to the Health insurance marketplace within 90 days)

Social Security Number

EMPLOYMENT AND ELIGIBILITY

Most recent job

This INCLUDES income from your spouse or child even if they aren’t on the plan. If W2 income before taxes. If 1099 income after deductions.

Estimated HOUSEHOLD Income for this year.

How many people need insurance? *

1 (Just You)

2

3 or more

Other than yourself, how many other people are on your tax return? (must file jointly if married to qualify)

Taxable household size

SINGLE MEMBER HOUSEHOLD

Do you claim anyone else on your taxes? *

I do not claim anyone else

I include other people (spouse, children, etc.)

2ND PERSON NEEDING INSURANCE

2nd person First Name

2nd person Last Name

2nd person Gender

Male

Female

2nd person's date of birth

(Social Security Number: OPTIONAL but if you don’t include it on our application you will need to send in proof of citizenship to the Health insurance marketplace within 90 days)

2nd persons Social Security Number

2nd Person relationship to 1st person

Do you only include 2 people on your tax return? *

Yes, there are only 2 people in my household

No, there are more people in my household

3RD PERSON NEEDING INSURANCE

3rd person First Name

3rd person Last Name

3rd person Gender

Male

Female

3rd person's date of birth

(Social Security Number: OPTIONAL but if you don’t include it on our application you will need to send in proof of citizenship to the Health insurance marketplace within 90 days)

3rd persons Social Security Number

3rd persons relationship to 1st person

Do you have any more household members to add? *

Yes

No

4TH HOUSEHOLD MEMBER

4th Household Member First Name

4th Household Member Last Name

4th Household Member Date of birth

Do you have any more household members to add? *

Yes

No

5TH HOUSEHOLD MEMBER

5th Household Member First Name

5th Household Member Last Name

5th Household Member Date of birth *

Enter the rest of the names and date(s) of birth *

Disclaimer

I hereby grant permission to Nino Palermo NPN 19623606 and The Palermo Group and their affiliates to act as the health insurance agent or broker for myself and, if applicable, my entire household, for the purposes of enrolling in a Qualified Health Plan offered on the Federally Facilitated Marketplace, specifically at the minimum income required to qualify in my state. By signing this agreement, I authorize the aforementioned Agent to access, view, and utilize the confidential information supplied by me, whether in writing, electronically, or over the phone, exclusively for the following activities: Searching for an existing Marketplace application; Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan, other government affordability insurance programs like Medicaid, CHIP, or advance tax credits to assist with Marketplace premiums; Providing continuous account maintenance and required enrollment support; Responding to inquiries from the Marketplace concerning my application. I acknowledge and understand that Nino Palermo NPN 19623606 and The Palermo Group and their affiliates will not employ or disseminate my personally identifiable information (PII) for reasons other than those specified above. The agency commits to ensuring the confidentiality and security of my PII during its collection, storage, and use for the described objectives. I affirm that all the details I supply for my Marketplace eligibility and application are accurate to the best of my understanding. I recognize that I am not obligated to provide any additional personal or health-related data to my Agent beyond what the application demands for eligibility and registration. My consent will remain valid unless I choose to revoke it, and I retain the right to withdraw or adjust my consent by reaching out to Nino Palermo NPN 19623606 by Email only at any moment. I hereby attest that all the information provided is true and accurate to the best of my knowledge and grant Nino Palermo NPN 19623606 and The Palermo Group and their affiliates permission to process my application based on the information shared. *

Do you understand that this is a request to ENROLL you in the best FREE health insurance plan available in your area based on your household income, household size and Zip Code? (If you are not eligible for FREE coverage we will reach out to you to discuss alternative options) *

Yes

No

Do you understand that if the plan we enroll you in does not meet your needs you may cancel it at any time or reach out to us to discuss alternative options? *

Yes

No

HealthCare.gov access

Do you give us permission to access your healthcare.gov account if you have one, in order to enroll you in the best plan possible? *

Yes

No

Free Plan Eligibility

Do you understand that plan options vary based on household income, location, age and household size? *

Yes

No

Dependable Coverage

8887611246

david@dependablecoverage.us

Tonawanda, NY

Licensed In Several States

Tonawanda, NY