ACA Authorization Form

First

Last Name

Phone Number

Home Address

SSN

Tobacco User

US Citizen

Pregnant Y/N, if yes: how many months?

Spouse Name & Birthdate (write n/a if no spouse)

Children Names & Birthdates

Spouse and Children SSN's

Employer Name (for primary insured)

Notes

By signing your name in the field below, you agree to the Terms & Conditions of the ACA Authorization Form document linked right below the form.

By submitting the information on this form, you give consent to Terms & Conditions from this document. Click here to see the document.