rightwayinsurancegroup.com
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34.174.182.47
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URL:
https://rightwayinsurancegroup.com/health-credits/
Submission: On December 16 via api from US — Scanned from DE
Submission: On December 16 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: RWIG- healthcredtis — POST
<form class="elementor-form" method="post" id="RWIGACA" name="RWIG- healthcredtis">
<input type="hidden" name="post_id" value="1827">
<input type="hidden" name="form_id" value="51e2f78b">
<input type="hidden" name="referer_title" value="RightWay Insurance Group | Health Credits">
<input type="hidden" name="queried_id" value="1827">
<div class="elementor-form-fields-wrapper elementor-labels-above">
<div class="elementor-field-type-step elementor-column elementor-field-group-field_6fd907e elementor-col-100 e-form__step" style="">
<div class="e-field-step elementor-hidden" data-label="Step1" data-previousbutton="" data-nextbutton="" data-iconurl="" data-iconlibrary="fas fa-star"
data-icon="<svg class="e-font-icon-svg e-fas-star" viewBox="0 0 576 512" xmlns="http://www.w3.org/2000/svg"><path d="M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z"></path></svg>">
</div>
<div class="elementor-field-type-hidden elementor-field-group elementor-column elementor-field-group-UTM elementor-col-100">
<input size="1" type="hidden" name="form_fields[UTM]" id="form-field-UTM" class="elementor-field elementor-size-sm elementor-field-textual">
</div>
<div class="elementor-field-type-hidden elementor-field-group elementor-column elementor-field-group-date_created elementor-col-100">
<input size="1" type="hidden" name="form_fields[date_created]" id="form-field-date_created" class="elementor-field elementor-size-sm elementor-field-textual">
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-Permission elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-Permission" class="elementor-field-label"> I give permission to Right Way Insurance Group LLC and it’s affiliates to access and/or create my application for health insurance on the Federally Facilitated Marketplace
(FFM) based on the information I am providing below. </label>
<div class="elementor-field-subgroup elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="Yes, I give Permision." id="form-field-Permission-0" name="form_fields[Permission]" required="required"
aria-required="true"> <label for="form-field-Permission-0">Yes, I give Permision.</label></span></div>
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-insurance_through_employer elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-insurance_through_employer" class="elementor-field-label"> Do you have insurance through your employer, Medicare, Medicaid or VA? </label>
<div class="elementor-field-subgroup elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="Yes" id="form-field-insurance_through_employer-0" name="form_fields[insurance_through_employer]"
required="required" aria-required="true"> <label for="form-field-insurance_through_employer-0">Yes</label></span><span class="elementor-field-option"><input type="radio" value="No" id="form-field-insurance_through_employer-1"
name="form_fields[insurance_through_employer]" required="required" aria-required="true"> <label for="form-field-insurance_through_employer-1">No</label></span></div>
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-MA_DOB elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-MA_DOB" class="elementor-field-label"> Main Applicant Date of Birth </label>
<input size="1" type="text" name="form_fields[MA_DOB]" id="form-field-MA_DOB" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter: MM-DD-YYYY" required="required" aria-required="true" inputmode="numeric">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-fname elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-fname" class="elementor-field-label"> First Name </label>
<input size="1" type="text" name="form_fields[fname]" id="form-field-fname" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter First Name" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-lname elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-lname" class="elementor-field-label"> Last Name </label>
<input size="1" type="text" name="form_fields[lname]" id="form-field-lname" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter Last Name" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-phone elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-phone" class="elementor-field-label"> Phone Number </label>
<input size="1" type="text" name="form_fields[phone]" id="form-field-phone" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter Phone Number" required="required" aria-required="true" minlength="10"
maxlength="10">
</div>
<div class="elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-email" class="elementor-field-label"> Email </label>
<input size="1" type="email" name="form_fields[email]" id="form-field-email" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter Email" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-address elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-address" class="elementor-field-label"> Address </label>
<input size="1" type="text" name="form_fields[address]" id="form-field-address" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter Address" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-city elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-city" class="elementor-field-label"> City </label>
<input size="1" type="text" name="form_fields[city]" id="form-field-city" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter City" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-State elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-State" class="elementor-field-label"> State </label>
<input size="1" type="text" name="form_fields[State]" id="form-field-State" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter State" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-zipcode elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-zipcode" class="elementor-field-label"> Zip Code </label>
<input size="1" type="text" name="form_fields[zipcode]" id="form-field-zipcode" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter Zip Code" required="required" aria-required="true" minlength="5"
maxlength="5">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-SSN elementor-col-33 elementor-field-required elementor-mark-required">
<label for="form-field-SSN" class="elementor-field-label"> Social Security Number </label>
<input size="1" type="text" name="form_fields[SSN]" id="form-field-SSN" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Social Security Number" required="required" aria-required="true" minlength="9"
maxlength="9">
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-gender elementor-col-33 elementor-field-required elementor-mark-required">
<label for="form-field-gender" class="elementor-field-label"> Gender </label>
<div class="elementor-field-subgroup elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="Male" id="form-field-gender-0" name="form_fields[gender]" required="required" aria-required="true"> <label
for="form-field-gender-0">Male</label></span><span class="elementor-field-option"><input type="radio" value="Female" id="form-field-gender-1" name="form_fields[gender]" required="required" aria-required="true"> <label
for="form-field-gender-1">Female</label></span></div>
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-Marital_Status elementor-col-33 elementor-field-required elementor-mark-required">
<label for="form-field-Marital_Status" class="elementor-field-label"> Marital Status </label>
<div class="elementor-field-subgroup elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="Single" id="form-field-Marital_Status-0" name="form_fields[Marital_Status]" required="required"
aria-required="true"> <label for="form-field-Marital_Status-0">Single</label></span><span class="elementor-field-option"><input type="radio" value="Married" id="form-field-Marital_Status-1" name="form_fields[Marital_Status]"
required="required" aria-required="true"> <label for="form-field-Marital_Status-1">Married</label></span></div>
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-spouse_Fname elementor-col-50 elementor-field-required elementor-mark-required hidden">
<label for="form-field-spouse_Fname" class="elementor-field-label"> Spouse First Name </label>
<input size="1" type="text" name="form_fields[spouse_Fname]" id="form-field-spouse_Fname" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter Spouse First Name" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-spouse_Lname elementor-col-50 elementor-field-required elementor-mark-required hidden">
<label for="form-field-spouse_Lname" class="elementor-field-label"> Spouse Last Name </label>
<input size="1" type="text" name="form_fields[spouse_Lname]" id="form-field-spouse_Lname" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter Spouse Last Name" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-spouse_dob elementor-col-50 elementor-field-required elementor-mark-required hidden">
<label for="form-field-spouse_dob" class="elementor-field-label"> Spouse Date of Birth </label>
<input size="1" type="text" name="form_fields[spouse_dob]" id="form-field-spouse_dob" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter MM-DD-YYYY" aria-required="true" inputmode="numeric">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-spouse_ssn elementor-col-50 hidden">
<label for="form-field-spouse_ssn" class="elementor-field-label"> Spouse SSN <i style="color:#169625;"> (Only if adding to the plan)</i> </label>
<input size="1" type="text" name="form_fields[spouse_ssn]" id="form-field-spouse_ssn" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter your Spouse SSN (Only numbers)" minlength="9" maxlength="9">
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-spouse_gender elementor-col-40 elementor-field-required elementor-mark-required hidden">
<label for="form-field-spouse_gender" class="elementor-field-label"> Spouse Gender </label>
<div class="elementor-field-subgroup elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="Male" id="form-field-spouse_gender-0" name="form_fields[spouse_gender]" aria-required="true"> <label
for="form-field-spouse_gender-0">Male</label></span><span class="elementor-field-option"><input type="radio" value="Female" id="form-field-spouse_gender-1" name="form_fields[spouse_gender]" aria-required="true"> <label
for="form-field-spouse_gender-1">Female</label></span></div>
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-dependents elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-dependents" class="elementor-field-label"> Will you be claiming any dependents on your taxes in 2023? </label>
<div class="elementor-field-subgroup elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="Yes" id="form-field-dependents-0" name="form_fields[dependents]" required="required" aria-required="true"> <label
for="form-field-dependents-0">Yes</label></span><span class="elementor-field-option"><input type="radio" value="No" id="form-field-dependents-1" name="form_fields[dependents]" required="required" aria-required="true"> <label
for="form-field-dependents-1">No</label></span></div>
</div>
<div class="elementor-field-type-repeater_start elementor-field-group elementor-column elementor-field-group-dependents_name elementor-col-100">
<div class="elementor-field-repeater-start">
<textarea class="repeater-field-header-data hidden"><div class="repeater-field-header">
<div class="repeater-field-header-title">Dependent <span class="repeater-field-header-count">1</span></div>
<div class="repeater-field-header-acctions">
<ul>
<li><i class="repeater-icon icon-down-open repeater-field-header-acctions-toogle" aria-hidden="true"></i></li>
<li><i class="repeater-icon icon-cancel-1 repeater-field-header-acctions-remove" aria-hidden="true"></i></li>
</ul>
</div>
</div></textarea>
</div>
</div>
<div class="elementor-field-type-repeater elementor-field-group elementor-column elementor-field-group-field_e63c3da elementor-col-100 hidden" data-id="1">
<div class="elementor-field-repeater-end" data-initial_rows="1" data-limit="5">
<div class="repeater-field-warp-item">
<div class="repeater-field-item">
<div class="repeater-field-header">
<div class="repeater-field-header">
<div class="repeater-field-header-title">Dependent <span class="repeater-field-header-count">1</span></div>
<div class="repeater-field-header-acctions">
<ul>
<li><i class="repeater-icon icon-down-open repeater-field-header-acctions-toogle" aria-hidden="true"></i></li>
<li><i class="repeater-icon icon-cancel-1 repeater-field-header-acctions-remove" aria-hidden="true"></i></li>
</ul>
</div>
</div>
</div>
<div class="repeater-field-content">
<div class="container-repeater-field" data-id="8995">
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-dep_Fname-8995 elementor-col-33 elementor-field-required elementor-mark-required">
<label for="form-field-dep_Fname" class="elementor-field-label"> First Name </label>
<input size="1" type="text" name="form_fields[dep_Fname][8995]" id="form-field-dep_Fname-8995" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter First Name" required="required"
aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-dep_Lname-8995 elementor-col-33 elementor-field-required elementor-mark-required">
<label for="form-field-dep_Lname" class="elementor-field-label"> Last Name </label>
<input size="1" type="text" name="form_fields[dep_Lname][8995]" id="form-field-dep_Lname-8995" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter Last Name" required="required"
aria-required="true">
</div>
<div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-dep_gender-8995 elementor-col-33 elementor-field-required elementor-mark-required">
<label for="form-field-dep_gender" class="elementor-field-label"> Gender </label>
<div class="elementor-field elementor-select-wrapper remove-before ">
<div class="select-caret-down-wrapper">
<svg aria-hidden="true" class="e-font-icon-svg e-eicon-caret-down" viewBox="0 0 571.4 571.4" xmlns="http://www.w3.org/2000/svg">
<path d="M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z"></path>
</svg>
</div>
<select name="form_fields[dep_gender][8995]" id="form-field-dep_gender-8995" class="elementor-field-textual elementor-size-sm" required="required" aria-required="true">
<option value="Select Gender">Select Gender</option>
<option value="Male">Male</option>
<option value="Female">Female</option>
</select>
</div>
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-dep_dob-8995 elementor-col-50 elementor-field-required elementor-mark-required">
<label for="form-field-dep_dob" class="elementor-field-label"> Date of Birth </label>
<input size="1" type="text" name="form_fields[dep_dob][8995]" id="form-field-dep_dob-8995" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter MM-DD-YYYY" required="required" aria-required="true">
</div>
<div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-dep_relationship-8995 elementor-col-50">
<label for="form-field-dep_relationship" class="elementor-field-label"> SSN <i style="color:#169625;"> (Only if adding to the plan)</i> </label>
<input size="1" type="text" name="form_fields[dep_relationship][8995]" id="form-field-dep_relationship-8995" class="elementor-field elementor-size-sm elementor-field-textual" placeholder="Enter SSN">
</div>
</div>
</div>
</div>
</div>
<div class="repeater-field-footer">
<div class="repeater-field-button-add">Add Dependent</div>
</div>
<input type="hidden" name="form_fields[field_e63c3da]" id="form-field-field_e63c3da" class="elementor-field elementor-size-sm elementor-field-repeater-data"
value="{"count":1,"fields":["form_fields[dep_Fname]","form_fields[dep_Lname]","form_fields[dep_gender]","form_fields[dep_dob]","form_fields[dep_relationship]"],"id":[8995]}">
<textarea class="elementor-field-repeater-data-html hidden"></textarea>
</div>
</div>
<div class="elementor-field-type-range elementor-field-group elementor-column elementor-field-group-household_income elementor-col-66 elementor-field-required elementor-mark-required">
<label for="form-field-household_income" class="elementor-field-label"> What is your estimated Household Income for 2023? </label>
<span class="irs irs--flat js-irs-0 irs-with-grid"><span class="irs"><span class="irs-line" tabindex="0"></span><span class="irs-min" style="visibility: visible;">$11 000</span><span class="irs-max" style="visibility: visible;">$36
000</span><span class="irs-from" style="visibility: hidden;">0</span><span class="irs-to" style="visibility: hidden;">0</span><span class="irs-single" style="left: 46.2%;">$23 500</span></span><span class="irs-grid"
style="width: 97.3654%; left: 1.21728%;"><span class="irs-grid-pol" style="left: 0%"></span><span class="irs-grid-text js-grid-text-0" style="left: 0%; margin-left: -2.70531%;">11 000</span><span class="irs-grid-pol small"
style="left: 20%"></span><span class="irs-grid-pol small" style="left: 15%"></span><span class="irs-grid-pol small" style="left: 10%"></span><span class="irs-grid-pol small" style="left: 5%"></span><span class="irs-grid-pol"
style="left: 25%"></span><span class="irs-grid-text js-grid-text-1" style="left: 25%; visibility: visible; margin-left: -2.76062%;">17 250</span><span class="irs-grid-pol small" style="left: 45%"></span><span class="irs-grid-pol small"
style="left: 40%"></span><span class="irs-grid-pol small" style="left: 35%"></span><span class="irs-grid-pol small" style="left: 30%"></span><span class="irs-grid-pol" style="left: 50%"></span><span class="irs-grid-text js-grid-text-2"
style="left: 50%; visibility: visible; margin-left: -2.76062%;">23 500</span><span class="irs-grid-pol small" style="left: 70%"></span><span class="irs-grid-pol small" style="left: 65%"></span><span class="irs-grid-pol small"
style="left: 60%"></span><span class="irs-grid-pol small" style="left: 55%"></span><span class="irs-grid-pol" style="left: 75%"></span><span class="irs-grid-text js-grid-text-3"
style="left: 75%; visibility: visible; margin-left: -2.76062%;">29 750</span><span class="irs-grid-pol small" style="left: 95%"></span><span class="irs-grid-pol small" style="left: 90%"></span><span class="irs-grid-pol small"
style="left: 85%"></span><span class="irs-grid-pol small" style="left: 80%"></span><span class="irs-grid-pol" style="left: 100%"></span><span class="irs-grid-text js-grid-text-4" style="left: 100%; margin-left: -2.76062%;">36
000</span></span><span class="irs-bar irs-bar--single" style="left: 0px; width: 50%;"></span><span class="irs-shadow shadow-single" style="display: none;"></span><span class="irs-handle single"
style="left: 48.6827%;"><i></i><i></i><i></i></span></span><input type="text" name="form_fields[household_income]" id="form-field-household_income"
class="elementor-field elementor-size-sm elementor-field-range-slider elementor-field-textual irs-hidden-input" required="required" aria-required="true" data-type="single" data-skin="flat" data-min="11000" data-max="36000" data-from="23500"
data-from-min="11000" data-from-max="36000" data-to="36000" data-to-min="36000" data-to-max="36000" data-step="1" data-prefix="$" data-postfix="" data-grid="true" tabindex="-1" readonly="">
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-is_this elementor-col-33 elementor-field-required elementor-mark-required">
<label for="form-field-is_this" class="elementor-field-label"> Is this </label>
<div class="elementor-field-subgroup elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="Monthly" id="form-field-is_this-0" name="form_fields[is_this]" required="required" aria-required="true"> <label
for="form-field-is_this-0">Monthly</label></span><span class="elementor-field-option"><input type="radio" value="Yearly" id="form-field-is_this-1" name="form_fields[is_this]" required="required" aria-required="true"> <label
for="form-field-is_this-1">Yearly</label></span></div>
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-best_option elementor-col-60 elementor-field-required elementor-mark-required">
<label for="form-field-best_option" class="elementor-field-label"> Which $0 plan carriers are you interested in? </label>
<div class="elementor-field-subgroup "><span class="elementor-field-option"><input type="radio" value="<b>Best Option (Recommended)</b>" id="form-field-best_option-0" name="form_fields[best_option]" checked="checked" required="required"
aria-required="true"> <label for="form-field-best_option-0"><b>Best Option (Recommended)</b></label></span><span class="elementor-field-option"><input type="radio" value="Ambetter" id="form-field-best_option-1"
name="form_fields[best_option]" required="required" aria-required="true"> <label for="form-field-best_option-1">Ambetter</label></span><span class="elementor-field-option"><input type="radio" value="Aetna" id="form-field-best_option-2"
name="form_fields[best_option]" required="required" aria-required="true"> <label for="form-field-best_option-2">Aetna</label></span><span class="elementor-field-option"><input type="radio" value="Cigna" id="form-field-best_option-3"
name="form_fields[best_option]" required="required" aria-required="true"> <label for="form-field-best_option-3">Cigna</label></span><span class="elementor-field-option"><input type="radio" value="Molina" id="form-field-best_option-4"
name="form_fields[best_option]" required="required" aria-required="true"> <label for="form-field-best_option-4">Molina</label></span><span class="elementor-field-option"><input type="radio" value="UHC" id="form-field-best_option-5"
name="form_fields[best_option]" required="required" aria-required="true"> <label for="form-field-best_option-5">UHC</label></span><span class="elementor-field-option"><input type="radio" value="Oscar" id="form-field-best_option-6"
name="form_fields[best_option]" required="required" aria-required="true"> <label for="form-field-best_option-6">Oscar</label></span></div>
</div>
<div class="elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_52e0d9b elementor-col-100"> * If your plan choice is not available, a licensed agent will choose the best available $0 option for you
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_a2b94b9 elementor-col-100">
<label for="form-field-field_a2b94b9" class="elementor-field-label"> Income Verification </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_a2b94b9]" id="form-field-field_a2b94b9" rows="3"
placeholder="By clicking the checkbox below, I hereby provide consent and authorization to Right Way Insurance Group LLC and/or its affiliates to submit my estimated income within a range of 20% above or below the estimated income that I provided on this application. I also provide consent and authorization to Right Way Insurance Group LLC and/or its affiliates to submit an income verification letter on my behalf if required by the marketplace."
readonly="readonly"></textarea>
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-income_agreement elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-income_agreement" class="elementor-field-label"> Do you Agree with the Income Verification? </label>
<div class="elementor-field-subgroup "><span class="elementor-field-option"><input type="radio" value="Yes, I Agree" id="form-field-income_agreement-0" name="form_fields[income_agreement]" required="required" aria-required="true"> <label
for="form-field-income_agreement-0">Yes, I Agree</label></span></div>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-afield_a2b94b9 elementor-col-100">
<label for="form-field-afield_a2b94b9" class="elementor-field-label"> Consent to Enrollment; Verification of Information </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[afield_a2b94b9]" id="form-field-afield_a2b94b9" rows="5"
placeholder="By clicking the checkbox below, I hereby provide consent and authorization To Right Way Insurance Group LLC. To enroll me and/or my family in a health insurance plan through the ACA Marketplace. If I already have a plan, I request that Right Way Insurance Group LLC and/or its affiliates become my agent of record and switch me to a better plan if one is available. This consent will remain in effect unless and until rescinded by you in writing by emailing help@rightwayinsurancegroup.com or calling (888) 261-0585."
readonly="readonly"></textarea>
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-enrollment_agreement elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-enrollment_agreement" class="elementor-field-label"> Do you Agree with the Consent? </label>
<div class="elementor-field-subgroup "><span class="elementor-field-option"><input type="radio" value="Yes, I Agree" id="form-field-enrollment_agreement-0" name="form_fields[enrollment_agreement]" required="required" aria-required="true">
<label for="form-field-enrollment_agreement-0">Yes, I Agree</label></span></div>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_a2b94b9 elementor-col-100 elementor-sm-100">
<label for="form-field-field_a2b94b9" class="elementor-field-label"> Authorization and Tax attestation </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_a2b94b9]" id="form-field-field_a2b94b9" rows="10"
placeholder="If another agent goes into your application and changes the agent of record, we will no longer have access to your policy. Should that happen, do you give permission to our agency to go back in and be listed as agent of record?. [ Renewal Authorization: ] Open Enrollment begins Nov 1st of every year. This is when we need to re-enroll your health policy with us. Do you authorize us to auto-renew your insurance policy and change your plan to a different company if needed to ensure your plan remains $0 even if there is a different network of doctors? This allows us to remain agent of record and ensure your coverage does not lapse. [ Tax Attestation ] Please confirm that you: (1) Agree to allow the Marketplace to use your income data, including information from tax returns, for the next 5 years; (2) understand that you are not eligible for a premium tax credit if found eligible for other qualifying health coverage, such as Medicaid, CHIP, or a job-based health plan; (3) understand that if you become eligible for other qualifying health coverage, you must contact the Marketplace to end your coverage and premium tax credit; (4) understand if the income on your tax return is higher than the amount of income on your application, you may owe additional federal income tax; (5) You agree that you have provided true answers to all of the questions to the best of your knowledge, and you know you may be subject to penalties under federal law if you intentionally provide false information. You attest that your estimated income for 2024 will be at least the Federal Poverty Limit for your state and household requirements . You agree to notify us as soon as you become aware of any changes to expected income per month that you provided above. Failure to notify us of any changes may result in your eligibility being affected."
readonly="readonly"></textarea>
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-tax_agreement elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-tax_agreement" class="elementor-field-label"> Do you Agree with Authorization and Tax attestation? </label>
<div class="elementor-field-subgroup "><span class="elementor-field-option"><input type="radio" value="Yes, I Agree" id="form-field-tax_agreement-0" name="form_fields[tax_agreement]" required="required" aria-required="true"> <label
for="form-field-tax_agreement-0">Yes, I Agree</label></span></div>
</div>
<div class="elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_a2b94b9 elementor-col-100 elementor-sm-100">
<label for="form-field-field_a2b94b9" class="elementor-field-label"> Consent Acknowledgement </label>
<textarea class="elementor-field-textual elementor-field elementor-size-sm" name="form_fields[field_a2b94b9]" id="form-field-field_a2b94b9" rows="10"
placeholder="By clicking “I Agree”, I am providing my electronic signature expressly authorizing Peace Tree Insurance, LLC and/or its affiliate to contact me by email, phone or text (including an automatic dialing system or artificial/pre-recorded voice) at the home or cell phone number above. I understand I am not required to sign/agree to this as a condition to purchase. I give my permission to Right Way Insurance Group LLC and/or its affiliates to serve as the health insurance agency, agent, and/or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned agency, agent, and/or broker to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: 1- Searching for an existing Marketplace application; 2- Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums; 3- Providing ongoing account maintenance and enrollment assistance, as necessary; or 4- Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the agency, agent, and/or broker will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agency, agent, and/or broker will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provided for entry on my Marketplace eligibility and enrollment application is true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agency, agent, and/or broker beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by emailing help@rightwayinsurancegroup.com or calling (888) 261-0585."
readonly="readonly"></textarea>
</div>
<div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-consent_acknowlegdement elementor-col-100 elementor-field-required elementor-mark-required">
<label for="form-field-consent_acknowlegdement" class="elementor-field-label"> Do you Agree with Consent Acknowledgement? </label>
<div class="elementor-field-subgroup "><span class="elementor-field-option"><input type="radio" value="Yes, I Agree" id="form-field-consent_acknowlegdement-0" name="form_fields[consent_acknowlegdement]" required="required"
aria-required="true"> <label for="form-field-consent_acknowlegdement-0">Yes, I Agree</label></span></div>
</div>
<div class="elementor-field-type-signature elementor-field-group elementor-column elementor-field-group-signature elementor-col-100 elementor-sm-100 elementor-field-required elementor-mark-required">
<label for="form-field-signature" class="elementor-field-label"> Signature </label>
<div class="width-100">
<div class="elementor-signature-container" style="width: 350px">
<div class="elementor_signature_clear"><img src="https://rightwayinsurancegroup.com/wp-content/plugins/elementor-signature/lib/images/remove-icon.png" alt=""></div>
<div class="elementor-signature-field kbw-signature" data-id="signature" data-background="#ffffff" data-color="#000000" data-width="350" data-height="200" data-name="0" style="width:350px; height: 200px; background: #ffffff"><canvas
width="348" height="198">Your browser doesn't support signing</canvas></div>
</div> <input style="display: none;" type="text" name="form_fields[signature]" id="form-field-signature" class="elementor-field elementor-size-sm elementor-upload-field-signature" required="required" aria-required="true">
</div>
</div>
<div class="elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_c094f15 elementor-col-100"> By signing, I grant permission to act on my behalf and that of my entire household in matters related to
enrollment in a Qualified Health Plan via the Federally Facilitated Marketplace. This authorization also extends to any authorized representative or power of attorney acting on my behalf. The agents empowered by this agreement are Right Way
Insurance Group LLC and/or its affiliates. These agents are authorized to locate existing Marketplace applications, complete applications for eligibility in various plans and programs, provide necessary ongoing maintenance, and respond to
inquiries about my application from the Marketplace. I understand and agree that my personally identifiable information will be accessed and used solely for the objectives specified in this document. I attest that all the details I provide
for the purposes of eligibility and enrollment will be accurate to the best of my ability. I am under no obligation to disclose additional personal or health-related information beyond what is required for these applications. My consent
remains effective until I choose to revoke it. For any modifications or to revoke this consent, I can email help@rightwayinsurancegroup.com or by calling (888) 261-0585. </div>
<div class="e-form__buttons elementor-column elementor-col-100">
<div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-next"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-next">Review
Application</button></div>
</div>
</div>
<div class="elementor-field-type-step elementor-column elementor-field-group-field_ff56ea6 elementor-col-100 e-form__step elementor-hidden" style="">
<div class="e-field-step elementor-hidden" data-label="Step2" data-previousbutton="" data-nextbutton="" data-iconurl="" data-iconlibrary="fas fa-star"
data-icon="<svg class="e-font-icon-svg e-fas-star" viewBox="0 0 576 512" xmlns="http://www.w3.org/2000/svg"><path d="M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z"></path></svg>">
</div>
<div class="elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7758c92 elementor-col-100">
<div data-elementor-type="page" data-elementor-id="1761" class="elementor elementor-1761" data-elementor-post-type="elementor_library">
<div class="elementor-element elementor-element-11e64605 e-flex e-con-boxed e-con e-parent" data-id="11e64605" data-element_type="container"
data-settings="{"container_type":"flex","content_width":"boxed"}" data-core-v316-plus="true">
<div class="e-con-inner">
<div class="elementor-element elementor-element-d5bae26 elementor-widget elementor-widget-heading" data-id="d5bae26" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<h2 class="elementor-heading-title elementor-size-default">Review Your Application</h2>
</div>
</div>
<div class="elementor-element elementor-element-1dd688e5 e-grid e-con-full e-con e-child" data-id="1dd688e5" data-element_type="container"
data-settings="{"container_type":"grid","content_width":"full","grid_columns_grid":{"unit":"fr","size":2,"sizes":[]},"grid_rows_grid":{"unit":"fr","size":10,"sizes":[]},"grid_outline":"yes","grid_columns_grid_tablet":{"unit":"fr","size":"","sizes":[]},"grid_columns_grid_mobile":{"unit":"fr","size":1,"sizes":[]},"grid_rows_grid_tablet":{"unit":"fr","size":"","sizes":[]},"grid_rows_grid_mobile":{"unit":"fr","size":"","sizes":[]},"grid_auto_flow":"row","grid_auto_flow_tablet":"row","grid_auto_flow_mobile":"row"}">
<div class="elementor-element elementor-element-2d666bed elementor-widget elementor-widget-heading" data-id="2d666bed" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">First Name</p>
</div>
</div>
<div class="elementor-element elementor-element-2cf23a76 elementor-widget elementor-widget-heading" data-id="2cf23a76" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%first-name%</p>
</div>
</div>
<div class="elementor-element elementor-element-725c35a0 elementor-widget elementor-widget-heading" data-id="725c35a0" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Applicant Date of Birth</p>
</div>
</div>
<div class="elementor-element elementor-element-3306736e elementor-widget elementor-widget-heading" data-id="3306736e" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%mm-dd-YYYY%</p>
</div>
</div>
<div class="elementor-element elementor-element-bd481a5 elementor-widget elementor-widget-heading" data-id="bd481a5" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Last Name</p>
</div>
</div>
<div class="elementor-element elementor-element-1b01dedc elementor-widget elementor-widget-heading" data-id="1b01dedc" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%Last-name%</p>
</div>
</div>
<div class="elementor-element elementor-element-47dcb6e5 elementor-widget elementor-widget-heading" data-id="47dcb6e5" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Gender</p>
</div>
</div>
<div class="elementor-element elementor-element-ee0d456 elementor-widget elementor-widget-heading" data-id="ee0d456" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%gender%</p>
</div>
</div>
<div class="elementor-element elementor-element-2631eed5 elementor-widget elementor-widget-heading" data-id="2631eed5" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Marital Status</p>
</div>
</div>
<div class="elementor-element elementor-element-d82e61d elementor-widget elementor-widget-heading" data-id="d82e61d" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%marital status%</p>
</div>
</div>
<div class="elementor-element elementor-element-6f9b6740 elementor-widget elementor-widget-heading" data-id="6f9b6740" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Phone</p>
</div>
</div>
<div class="elementor-element elementor-element-78e95407 elementor-widget elementor-widget-heading" data-id="78e95407" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%Phone%</p>
</div>
</div>
<div class="elementor-element elementor-element-2414981e elementor-widget elementor-widget-heading" data-id="2414981e" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Email</p>
</div>
</div>
<div class="elementor-element elementor-element-1abc5ca2 elementor-widget elementor-widget-heading" data-id="1abc5ca2" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%Email%</p>
</div>
</div>
<div class="elementor-element elementor-element-55e22467 elementor-widget elementor-widget-heading" data-id="55e22467" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Address</p>
</div>
</div>
<div class="elementor-element elementor-element-5705e891 elementor-widget elementor-widget-heading" data-id="5705e891" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%Address%</p>
</div>
</div>
<div class="elementor-element elementor-element-70f9a64f elementor-widget elementor-widget-heading" data-id="70f9a64f" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">City</p>
</div>
</div>
<div class="elementor-element elementor-element-5a3fac93 elementor-widget elementor-widget-heading" data-id="5a3fac93" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%City%</p>
</div>
</div>
<div class="elementor-element elementor-element-cd70325 elementor-widget elementor-widget-heading" data-id="cd70325" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">State</p>
</div>
</div>
<div class="elementor-element elementor-element-22d1cfe4 elementor-widget elementor-widget-heading" data-id="22d1cfe4" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%state%</p>
</div>
</div>
<div class="elementor-element elementor-element-6c4436c7 elementor-widget elementor-widget-heading" data-id="6c4436c7" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Zip Code</p>
</div>
</div>
<div class="elementor-element elementor-element-184b63d8 elementor-widget elementor-widget-heading" data-id="184b63d8" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%zipcode%</p>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="e-form__buttons elementor-column elementor-col-100">
<div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-previous"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-previous">Edit
Application</button></div>
<div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-next"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-next">Next</button></div>
</div>
</div>
<div class="elementor-field-type-step elementor-column elementor-field-group-field_c7e8693 elementor-col-100 e-form__step elementor-hidden" style="">
<div class="e-field-step elementor-hidden" data-label="step 3" data-previousbutton="" data-nextbutton="" data-iconurl="" data-iconlibrary="fas fa-star"
data-icon="<svg class="e-font-icon-svg e-fas-star" viewBox="0 0 576 512" xmlns="http://www.w3.org/2000/svg"><path d="M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z"></path></svg>">
</div>
<div class="elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_39657f7 elementor-col-100">
<div data-elementor-type="page" data-elementor-id="1763" class="elementor elementor-1763" data-elementor-post-type="elementor_library">
<div class="elementor-element elementor-element-48d49f71 e-flex e-con-boxed e-con e-parent" data-id="48d49f71" data-element_type="container"
data-settings="{"container_type":"flex","content_width":"boxed"}" data-core-v316-plus="true">
<div class="e-con-inner">
<div class="elementor-element elementor-element-5bd691b elementor-widget elementor-widget-heading" data-id="5bd691b" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<h2 class="elementor-heading-title elementor-size-default">Review Your Application</h2>
</div>
</div>
<div class="elementor-element elementor-element-26012515 e-grid e-con-full e-con e-child" data-id="26012515" data-element_type="container"
data-settings="{"container_type":"grid","content_width":"full","grid_columns_grid":{"unit":"fr","size":2,"sizes":[]},"grid_rows_grid":{"unit":"fr","size":8,"sizes":[]},"grid_outline":"yes","grid_columns_grid_tablet":{"unit":"fr","size":"","sizes":[]},"grid_columns_grid_mobile":{"unit":"fr","size":1,"sizes":[]},"grid_rows_grid_tablet":{"unit":"fr","size":"","sizes":[]},"grid_rows_grid_mobile":{"unit":"fr","size":"","sizes":[]},"grid_auto_flow":"row","grid_auto_flow_tablet":"row","grid_auto_flow_mobile":"row"}">
<div class="elementor-element elementor-element-198f900 elementor-widget elementor-widget-heading" data-id="198f900" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Spouse Name</p>
</div>
</div>
<div class="elementor-element elementor-element-33b1ddba elementor-widget elementor-widget-heading" data-id="33b1ddba" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%spouse full name%</p>
</div>
</div>
<div class="elementor-element elementor-element-2d289db0 elementor-widget elementor-widget-heading" data-id="2d289db0" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Spouse DOB</p>
</div>
</div>
<div class="elementor-element elementor-element-19978caf elementor-widget elementor-widget-heading" data-id="19978caf" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%spouse DOB%</p>
</div>
</div>
<div class="elementor-element elementor-element-1c64b443 elementor-widget elementor-widget-heading" data-id="1c64b443" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Spouse Gender</p>
</div>
</div>
<div class="elementor-element elementor-element-1804b938 elementor-widget elementor-widget-heading" data-id="1804b938" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%spouse gender%</p>
</div>
</div>
<div class="elementor-element elementor-element-66a66fc8 elementor-widget elementor-widget-heading" data-id="66a66fc8" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Spouse SSN</p>
</div>
</div>
<div class="elementor-element elementor-element-290a1fd8 elementor-widget elementor-widget-heading" data-id="290a1fd8" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%spouse SSN%</p>
</div>
</div>
<div class="elementor-element elementor-element-6f3b0a5f elementor-widget elementor-widget-heading" data-id="6f3b0a5f" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Dependant 1 Name</p>
</div>
</div>
<div class="elementor-element elementor-element-323ed44f elementor-widget elementor-widget-heading" data-id="323ed44f" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%dependent-1-name%</p>
</div>
</div>
<div class="elementor-element elementor-element-56c5e419 elementor-widget elementor-widget-heading" data-id="56c5e419" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Dependent-1-gender</p>
</div>
</div>
<div class="elementor-element elementor-element-516f28ae elementor-widget elementor-widget-heading" data-id="516f28ae" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%dependent-1-gender%</p>
</div>
</div>
<div class="elementor-element elementor-element-5f717595 elementor-widget elementor-widget-heading" data-id="5f717595" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Dependent-1-DOB</p>
</div>
</div>
<div class="elementor-element elementor-element-27aa6b24 elementor-widget elementor-widget-heading" data-id="27aa6b24" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%dependent-1-DOB%</p>
</div>
</div>
<div class="elementor-element elementor-element-716a171d elementor-widget elementor-widget-heading" data-id="716a171d" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Dependent-1-relationship</p>
</div>
</div>
<div class="elementor-element elementor-element-5ebca343 elementor-widget elementor-widget-heading" data-id="5ebca343" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%dependent-1-relationship%</p>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="e-form__buttons elementor-column elementor-col-100">
<div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-previous"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-previous">Edit
Application</button></div>
<div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-next"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-next">Next</button></div>
</div>
</div>
<div class="elementor-field-type-step elementor-column elementor-field-group-field_4369838 elementor-col-100 e-form__step elementor-hidden" style="">
<div class="e-field-step elementor-hidden" data-label="step 4" data-previousbutton="" data-nextbutton="" data-iconurl="" data-iconlibrary="fas fa-star"
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<div data-elementor-type="page" data-elementor-id="1765" class="elementor elementor-1765" data-elementor-post-type="elementor_library">
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<div class="e-con-inner">
<div class="elementor-element elementor-element-a39a634 elementor-widget elementor-widget-heading" data-id="a39a634" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<h2 class="elementor-heading-title elementor-size-default">Review Your Application</h2>
</div>
</div>
<div class="elementor-element elementor-element-7ce9221d e-grid e-con-full e-con e-child" data-id="7ce9221d" data-element_type="container"
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<div class="elementor-element elementor-element-10fe8b82 elementor-widget elementor-widget-heading" data-id="10fe8b82" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Household Income</p>
</div>
</div>
<div class="elementor-element elementor-element-596f2be4 elementor-widget elementor-widget-heading" data-id="596f2be4" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%householdincome%</p>
</div>
</div>
<div class="elementor-element elementor-element-7166242b elementor-widget elementor-widget-heading" data-id="7166242b" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Monthly or Yearly</p>
</div>
</div>
<div class="elementor-element elementor-element-205c7e31 elementor-widget elementor-widget-heading" data-id="205c7e31" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%monthly-yearly%</p>
</div>
</div>
<div class="elementor-element elementor-element-21740ed9 elementor-widget elementor-widget-heading" data-id="21740ed9" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">$0 Plan Option</p>
</div>
</div>
<div class="elementor-element elementor-element-2f63de90 elementor-widget elementor-widget-heading" data-id="2f63de90" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%plan-option%</p>
</div>
</div>
<div class="elementor-element elementor-element-2bbbe87f elementor-widget elementor-widget-heading" data-id="2bbbe87f" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Income Verification</p>
</div>
</div>
<div class="elementor-element elementor-element-720fec38 elementor-widget elementor-widget-heading" data-id="720fec38" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%income-verification% ( I Agree)</p>
</div>
</div>
<div class="elementor-element elementor-element-3dad4a34 elementor-widget elementor-widget-heading" data-id="3dad4a34" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Consent to Enrollment</p>
</div>
</div>
<div class="elementor-element elementor-element-24fd460d elementor-widget elementor-widget-heading" data-id="24fd460d" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%Consent-to-Enrollment% ( I Agree)</p>
</div>
</div>
<div class="elementor-element elementor-element-6e5f0392 elementor-widget elementor-widget-heading" data-id="6e5f0392" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Authorization and Tax attestation </p>
</div>
</div>
<div class="elementor-element elementor-element-c721af0 elementor-widget elementor-widget-heading" data-id="c721af0" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%Authorization-Taxattestation% (I Agree)</p>
</div>
</div>
<div class="elementor-element elementor-element-18bf163c elementor-widget elementor-widget-heading" data-id="18bf163c" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Permission to Peace Tree Insurance LLC</p>
</div>
</div>
<div class="elementor-element elementor-element-3f0649 elementor-widget elementor-widget-heading" data-id="3f0649" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%permissionPeaceTreeInsurance% (YES)</p>
</div>
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<div class="elementor-element elementor-element-8b72fb2 elementor-widget elementor-widget-heading" data-id="8b72fb2" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Do you have insurance through your employer, Medicare, Medicaid or VA? </p>
</div>
</div>
<div class="elementor-element elementor-element-2a54436a elementor-widget elementor-widget-heading" data-id="2a54436a" data-element_type="widget" data-widget_type="heading.default">
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<p class="elementor-heading-title elementor-size-default">%Do you have insurance through your employer, Medicare, Medicaid or VA? %</p>
</div>
</div>
<div class="elementor-element elementor-element-3ed84f5b elementor-widget elementor-widget-heading" data-id="3ed84f5b" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">Consent Acknowledgement </p>
</div>
</div>
<div class="elementor-element elementor-element-27658840 elementor-widget elementor-widget-heading" data-id="27658840" data-element_type="widget" data-widget_type="heading.default">
<div class="elementor-widget-container">
<p class="elementor-heading-title elementor-size-default">%Consent Acknowledgement %</p>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="e-form__buttons elementor-column elementor-col-100">
<div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-previous"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-previous">Edit
Application</button></div>
<div class="elementor-field-group elementor-field-type-submit e-form__buttons__wrapper">
<button type="submit" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button">
<span>
<span class=" elementor-button-icon">
</span>
<span class="elementor-button-text">Submit Application</span>
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</div>
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</form>Text Content
OPEN ENROLLMENT 2023
CHECK ELIGIBILITY NOW
*Available Monday-Friday 10AM-7PM EST*
Rated 4.8 out of 5. Over 1,000 Reviews
5/5
$0 HEALTH INSURANCE PLAN + PREMIUM TAX CREDIT
CHECK ELIGIBILITY AND ENROLL TODAY
{"spouse_Fname":{"display":"show","trigger":"ALL","datas":[{"conditional_logic_id":"Marital_Status","conditional_logic_operator":"==","conditional_logic_value":"Married","_id":"0287e99"}]},"spouse_Lname":{"display":"show","trigger":"ALL","datas":[{"conditional_logic_id":"Marital_Status","conditional_logic_operator":"==","conditional_logic_value":"Married","_id":"0287e99"}]},"spouse_dob":{"display":"show","trigger":"ALL","datas":[{"conditional_logic_id":"Marital_Status","conditional_logic_operator":"==","conditional_logic_value":"Married","_id":"0287e99"}]},"spouse_ssn":{"display":"show","trigger":"ALL","datas":[{"conditional_logic_id":"Marital_Status","conditional_logic_operator":"==","conditional_logic_value":"Married","_id":"46f053d"}]},"spouse_gender":{"display":"show","trigger":"ALL","datas":[{"conditional_logic_id":"Marital_Status","conditional_logic_operator":"==","conditional_logic_value":"Married","_id":"46f053d"}]},"dependents_name":{"display":"show","trigger":"ALL","datas":[{"conditional_logic_id":"dependents","conditional_logic_operator":"==","conditional_logic_value":"Yes","_id":"bfa2b4d"}]},"field_e63c3da":{"display":"show","trigger":"ALL","datas":[{"conditional_logic_id":"dependents","conditional_logic_operator":"==","conditional_logic_value":"Yes","_id":"bfa2b4d"}]}}
I give permission to Right Way Insurance Group LLC and it’s affiliates to access
and/or create my application for health insurance on the Federally Facilitated
Marketplace (FFM) based on the information I am providing below.
Yes, I give Permision.
Do you have insurance through your employer, Medicare, Medicaid or VA?
Yes No
Main Applicant Date of Birth
First Name
Last Name
Phone Number
Email
Address
City
State
Zip Code
Social Security Number
Gender
Male Female
Marital Status
Single Married
Spouse First Name
Spouse Last Name
Spouse Date of Birth
Spouse SSN (Only if adding to the plan)
Spouse Gender
Male Female
Will you be claiming any dependents on your taxes in 2023?
Yes No
<div class="repeater-field-header"> <div
class="repeater-field-header-title">Dependent <span
class="repeater-field-header-count">1</span></div> <div
class="repeater-field-header-acctions"> <ul> <li><i class="repeater-icon
icon-down-open repeater-field-header-acctions-toogle"
aria-hidden="true"></i></li> <li><i class="repeater-icon icon-cancel-1
repeater-field-header-acctions-remove" aria-hidden="true"></i></li> </ul> </div>
</div>
Dependent 1
*
*
First Name
Last Name
Gender
Select Gender Male Female
Date of Birth
SSN (Only if adding to the plan)
Add Dependent
What is your estimated Household Income for 2023? $11 000$36 00000$23 50011
00017 25023 50029 75036 000
Is this
Monthly Yearly
Which $0 plan carriers are you interested in?
Best Option (Recommended) Ambetter Aetna Cigna Molina UHC Oscar
* If your plan choice is not available, a licensed agent will choose the best
available $0 option for you
Income Verification
Do you Agree with the Income Verification?
Yes, I Agree
Consent to Enrollment; Verification of Information
Do you Agree with the Consent?
Yes, I Agree
Authorization and Tax attestation
Do you Agree with Authorization and Tax attestation?
Yes, I Agree
Consent Acknowledgement
Do you Agree with Consent Acknowledgement?
Yes, I Agree
Signature
Your browser doesn't support signing
By signing, I grant permission to act on my behalf and that of my entire
household in matters related to enrollment in a Qualified Health Plan via the
Federally Facilitated Marketplace. This authorization also extends to any
authorized representative or power of attorney acting on my behalf. The agents
empowered by this agreement are Right Way Insurance Group LLC and/or its
affiliates. These agents are authorized to locate existing Marketplace
applications, complete applications for eligibility in various plans and
programs, provide necessary ongoing maintenance, and respond to inquiries about
my application from the Marketplace. I understand and agree that my personally
identifiable information will be accessed and used solely for the objectives
specified in this document. I attest that all the details I provide for the
purposes of eligibility and enrollment will be accurate to the best of my
ability. I am under no obligation to disclose additional personal or
health-related information beyond what is required for these applications. My
consent remains effective until I choose to revoke it. For any modifications or
to revoke this consent, I can email help@rightwayinsurancegroup.com or by
calling (888) 261-0585.
Review Application
REVIEW YOUR APPLICATION
First Name
%first-name%
Applicant Date of Birth
%mm-dd-YYYY%
Last Name
%Last-name%
Gender
%gender%
Marital Status
%marital status%
Phone
%Phone%
Email
%Email%
Address
%Address%
City
%City%
State
%state%
Zip Code
%zipcode%
Edit Application
Next
REVIEW YOUR APPLICATION
Spouse Name
%spouse full name%
Spouse DOB
%spouse DOB%
Spouse Gender
%spouse gender%
Spouse SSN
%spouse SSN%
Dependant 1 Name
%dependent-1-name%
Dependent-1-gender
%dependent-1-gender%
Dependent-1-DOB
%dependent-1-DOB%
Dependent-1-relationship
%dependent-1-relationship%
Edit Application
Next
REVIEW YOUR APPLICATION
Household Income
%householdincome%
Monthly or Yearly
%monthly-yearly%
$0 Plan Option
%plan-option%
Income Verification
%income-verification% ( I Agree)
Consent to Enrollment
%Consent-to-Enrollment% ( I Agree)
Authorization and Tax attestation
%Authorization-Taxattestation% (I Agree)
Permission to Peace Tree Insurance LLC
%permissionPeaceTreeInsurance% (YES)
Do you have insurance through your employer, Medicare, Medicaid or VA?
%Do you have insurance through your employer, Medicare, Medicaid or VA? %
Consent Acknowledgement
%Consent Acknowledgement %
Edit Application
Submit Application
CHECK ELIGIBILITY NOW
*Available Monday-Friday 10AM-7PM EST*
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