Health Insurance Application

Enter your information to get a quote on Florida Blue insurance plans through the ACA Marketplace.

First Name

Last Name

Date of Birth

Social Security #

Email Address

Phone Number

Sex

Are you a U.S. Citizen?

Do you use tobacco products?

Do you have medicaid?

Home Address (Florida)

Street Address

City

ZIP Code

County

State

Household Information

Annual Income ? It is better to provide a slightly higher estimate if you are unsure for tax reasons.

Are you married?

I do not claim dependents on my taxes and will not be this coming year.

Eligibility Questions

Eligibility Reason

Event Date

Event must have occurred in the past 60 days.

Estimated Subsidy ??

This is an estimate of the monthly subsidy you may be eligible for based on the information provided.

Plan Suggestion Type The plan below is a recommendation, and may not reflect all available options in your area.

Do you agree to be signed up for the plan above?

Do you agree to accept a premium after subsidy increase of up to $10 from between your current quote, or any price lower than the given quote?

Do you consent to receive text messages, calls, and emails from Salus Systems? Message frequency varies. Message and data rates may apply.

Do you confirm that you make your own healthcare decisions?

Review your application. Do you confirm that the information you provided is accurate?

I, , or my Authorized Representative acting on my behalf, hereby provide my consent for Peyton McQuillen (NPN: 20781867), Salus Systems, and their assistors, to provide me with information about my health insurance choices for the purpose of helping me apply for and enroll in health coverage through the Marketplace, and to access & submit my Marketplace application, as well as update or renew my application as needed. My consent will last 365 days, or until I revoke it by contacting agency@salussystems.co. I understand that I need to file a federal income tax return for the tax year 2026, and that no one will be able to claim me as a dependent on their 2026 tax return. I acknowledge that I am responsible for providing accurate and complete information—including income, household size, and other relevant data—on my Marketplace application. I understand that inaccurate or incomplete information may affect my eligibility for premium tax credits, cost-sharing reductions, or the suitability of coverage. I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, Children's Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit. I know that I must tell the program I’ll be enrolled in within 30 days if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). I know a change in my information could affect eligibility for member(s) of my household.

Do you confirm that you have read and agree to the above statements?

Health Insurance Application

Home Address (Florida)

Household Information

Eligibility Questions

Estimated Subsidy ??

$0.00/month was ??