I have NOT enrolled in a Marketplace/ACA Plan for 2024

Do not complete this form if you have already completed an enrollment in a Marketplace / ACA Health Insurance Plan for 2024 through either:

• The Marketplace / ACA.
• An Agent/Broker.

Only complete this form if you need assistance with Marketplace / ACA enrollment from BRHPC/American Exchange. American Exchange is a CMS Certified Federally Facilitated Marketplace Agent/Broker in the State of Florida and will act as your Agent of Record upon completing this form.

Before continuing, please ensure you have the required information to enroll:

• Tax Household Information (for all individuals in your Tax Household):
  • Legal Name (include hyphens, spaces, etc)
  • Date of Birth
  • Social Security Number
  • Income
• Household size
• Citizenship or Proof of legal residency (Immigration status indicating lawful presence)
• Address and preferred contact information