👤

Step 1 — About You

Basic personal details to find the right plans for you.

Full Legal Name *

Date of Birth *

Sex (as on legal documents) *

Social Security Number

U.S. Citizen or Legal Resident? *

Do you smoke or use tobacco? *

🚭 No 🚬 Yes

📏 Height & Weight (Optional)

Height — Feet

Height — Inches

Weight (lbs)

📍

Step 2 — How to Reach You

Your address helps us find local plans. We'll contact you with options.

Street Address *

City *

State *

ZIP Code *

County

Phone Number *

Email Address *

Mailing Address (if different from above)

👨‍👩‍👧 Beneficiary (Optional)

Beneficiary's Full Name

Relationship to You

Their Date of Birth

Their Phone Number

💵

Step 3 — Income & Employment

Helps us calculate your government discount — many people qualify for $0/month!

👤 Your Employment

Employer Name

Annual Income *

How do you file taxes? *

👫 Spouse's Employment (If married)

Spouse's Employer

Spouse's Annual Income

🏥

Step 4 — Current Health Coverage

Tell us what you have now so we can find you something better or more affordable.

Do you have ACA / Marketplace insurance? *

✅ Yes ❌ No

Are you receiving a government subsidy?

Yes No Not sure

COBRA coverage available?

COBRA offered date

Did you decline COBRA?

Other health benefits recently lost?

📋

Step 5 — Selected Plan & Fees

Filled in by Mercy's team during your consultation call.

📞You can leave this section blank. Mercy will call you and fill this in together at no obligation.

Plan Name

Monthly Premium

Application Fee

Total Amount Due

Marketplace / Application ID (Agent fills this)

Government Subsidy Amount

Coverage Start Date

💳

Step 6 — Payment Information

Complete when ready to enroll. Used to set up your monthly premium payment.

🔒Your payment details are fully encrypted and secure. We will never charge anything without your permission.

🏦 Bank Account

Bank Name

Routing Number

Account Number

💳 Credit / Debit Card (Alternative)

Card Type

Card Number

Expiration Date

CVV / Security Code

🦷

Step 7 — Dental, Vision, Life & Extra Info

Optional add-ons and details to find the best complete protection for you.

🦷 Dental Coverage

Major dental work in last 6 months?

Major dental work expected in next 6 months?

Would you like a dental insurance quote?

😁 Yes No

Add vision & hearing coverage?

👓 Yes No

❤️ Life Insurance

Do you currently have life insurance?

Yes No

If yes — describe your current life coverage

💊 Medications & Preferred Doctors

Current medications (separate with commas)

Doctors / specialists you'd like to keep

How did you hear about Insure With Mercy?

Anything else we should know?

🔐 For Agent Use Only

Agent Name

Agent National Producer Number

8193581

Date Application Completed

Enrollment Confirmation Number

Payment Date

Enrollment Date

Coverage Details Emailed On

Autopay Set Up?

Yes No

Thank You Card Sent?

Yes No

👤

Step 1 — About You

Basic personal details to find the right plans for you.

Full Legal Name *

Date of Birth *

Sex (as on legal documents) *

Social Security Number

U.S. Citizen or Legal Resident? *

Do you smoke or use tobacco? *

🚭 No 🚬 Yes

📏 Height & Weight (Optional)

Height — Feet

Height — Inches

Weight (lbs)

📍

Step 2 — How to Reach You

Your address helps us find local plans. We'll contact you with options.

Street Address *

City *

State *

ZIP Code *

County

Phone Number *

Email Address *

Mailing Address (if different from above)

👨‍👩‍👧 Beneficiary (Optional)

Beneficiary's Full Name

Relationship to You

Their Date of Birth

Their Phone Number

💵

Step 3 — Income & Employment

Helps us calculate your government discount — many people qualify for $0/month!

👤 Your Employment

Employer Name

Annual Income *

How do you file taxes? *

👫 Spouse's Employment (If married)

Spouse's Employer

Spouse's Annual Income

🏥

Step 4 — Current Health Coverage

Tell us what you have now so we can find you something better or more affordable.

Do you have ACA / Marketplace insurance? *

✅ Yes ❌ No

Are you receiving a government subsidy?

Yes No Not sure

COBRA coverage available?

COBRA offered date

Did you decline COBRA?

Other health benefits recently lost?

📋

Step 5 — Selected Plan & Fees

Filled in by Mercy's team during your consultation call.

📞You can leave this section blank. Mercy will call you and fill this in together at no obligation.

Plan Name

Monthly Premium

Application Fee

Total Amount Due

Marketplace / Application ID (Agent fills this)

Government Subsidy Amount

Coverage Start Date

💳

Step 6 — Payment Information

Complete when ready to enroll. Used to set up your monthly premium payment.

🔒Your payment details are fully encrypted and secure. We will never charge anything without your permission.

🏦 Bank Account

Bank Name

Routing Number

Account Number

💳 Credit / Debit Card (Alternative)

Card Type

Card Number

Expiration Date

CVV / Security Code

🦷

Step 7 — Dental, Vision, Life & Extra Info

Optional add-ons and details to find the best complete protection for you.

🦷 Dental Coverage

Major dental work in last 6 months?

Major dental work expected in next 6 months?

Would you like a dental insurance quote?

😁 Yes No

Add vision & hearing coverage?

👓 Yes No

❤️ Life Insurance

Do you currently have life insurance?

Yes No

If yes — describe your current life coverage

💊 Medications & Preferred Doctors

Current medications (separate with commas)

Doctors / specialists you'd like to keep

How did you hear about Insure With Mercy?

Anything else we should know?

🔐 For Agent Use Only

Agent Name

Agent National Producer Number

8193581

Date Application Completed

Enrollment Confirmation Number

Payment Date

Enrollment Date

Coverage Details Emailed On

Autopay Set Up?

Yes No

Thank You Card Sent?

Yes No

Free Health Insurance Application — Under 65

Free Health Insurance Application — Under 65