Who is myObamacare?

We’re a trusted professional health insurance agency serving the community since 2014

Are You Ready to Gain a Peace of Mind?

Obtain low to no cost health coverage from a trusted insurance carrier near you

Just a few questions, more than 90% of people who complete the form obtain health coverage starting the 1st of the month without speaking to an agent.

Qualified Form duplicate for 11-3-2025

Are you applying for coverage in one of the following states? NC SC FL GA TX TN OH AL MO MS VA LA

Yes

Are you applying for coverage in one of the following states?

Which qualifying event has occurred for you to have coverage on the 1st of the month? ( you will have to provide proof once your enrollment is complete)

Loss of Health Coverage

Move states

Addition to Family

Recently released from incarceration

How many need coverage?

Do you claim anyone else on your tax return who isn't applying for coverage today?

Yes

Enroll Now

Complete the form below to obtain LOW to NO Cost Health Insurance.

We’ll sign you up for the best health insurance plan in your area. We work with BCBS, Ambetter, Cigna, Caresource, Molina, United Health Care and many others. We aim to select the plan with the lowest copays and best coverage available while keeping your premium LOW to NO Cost to you!

Enroll Now

Complete the form below to obtain LOW to NO Cost Health Insurance.

First Name

Last Name

First Name

Last Name

Date of Birth

Address Line 1

Address Line 2

Gender

Male

Female

Phone

Gender

Male

Female

Phone

Household Income

Most Recent job description

Household Income

If making less than 138% of federal poverty limit, I agree I am looking for a job making more than that

Other insurance
Do you have other insurance through work, VA beenfits, healthcare.gov, medicare, etc?
If you have other insurance, we can not enroll you in a plan

Yes

Qualifying Event

Which qualifying event has occurred for you to enroll in special enrollment?

What date is/will this event happen? (what date will your health coverage be cancelled)

Which qualifying event has occurred for you to enroll in special enrollment?

What date is/will this event happen? (what date will your health coverage be cancelled)

Social security number to verify citizenship

We can’t submit your application without your SSN. If you leave it blank we will send text reminders
for you to call in your social security number on a recorded line.

if SSN isn’t valid, we will not submit the application for insurance & you will not have coverage

Social security number to verify citizenship

We can’t submit your application without your SSN. If you leave it blank we will send text reminders
for you to call in your social security number on a recorded line.

if SSN isn’t valid, we will not submit the application for insurance & you will not have coverage

Other taxable dependents in the household?

In addition to yourself, how many other people are in your taxable household that do NOT need insurance.
Please provide their full name, date of birth and relationship to you

How many other people are in your taxable household

Household Member Details.

Please provide their full name, date of birth and relationship to you

Info to help us choose the best plan for you

IF you want a specific plan or insurance carrier mention it here or anything else that
we may need to know to help you.

Info to help us choose the best plan for you

IF you want a specific plan or insurance carrier mention it here or anything else that
we may need to know to help you.

Robots can’t get insurance! What is 5+3=

Yes! I give permission to apply for free health insurance

I confirm that the information provided above is true and accurate to the best of my knowledge.

Yes! I give permission to apply for free health insurance

I confirm that the information provided above is true and accurate to the best of my knowledge.

Signature

Sign Here

Signature

Sign Here

Are there only 2 people in the household on your tax return?

Yes

Enroll Now

Complete the form below to obtain LOW to NO Cost Health Insurance.

Enroll Now

Complete the form below to obtain LOW to NO Cost Health Insurance.

We’ll sign you up for the best health insurance plan in your area. We work with BCBS, Ambetter, Cigna, Caresource, Molina,
United Health Care and many others. We aim to select the plan with the lowest copays and best coverage available while keeping your premium LOW to NO Cost to you!

First Name

Last Name

First Name

Last Name

Date of Birth

Address Line 1

Address Line 2

Address Line 1

Address Line 2

Phone/Mobile

Gender

Male

Female

Gender

Male

Female

Social security number to verify citizenship

We can’t submit your application without your SSN. If you leave it blank we will send text reminders
for you to call in your social security number on a recorded line.

if SSN isn’t valid, we will not submit the application for insurance & you will not have coverage

Social security number to verify citizenship

We can’t submit your application without your SSN. If you leave it blank we will send text reminders
for you to call in your social security number on a recorded line.

if SSN isn’t valid, we will not submit the application for insurance & you will not have coverage

2nd person needing insurance

First Name

Last Name

First Name

Last Name

2nd person’s gender

Male

Female

2nd persons Date of Birth

2nd person’s gender

Male

Female

2nd persons Date of Birth

2nd persons social security number
you have 90 days to submit their SSN, if you do not the government will cancel your insurance

Relationship to 1st person

Qualifying Event

Which qualifying event has occurred for you to enroll in special enrollment?

What date is/will this event happen? (what date will your health coverage be cancelled)

Which qualifying event has occurred for you to enroll in special enrollment?

What date is/will this event happen? (what date will your health coverage be cancelled)

Most Recent job description

Household Income

Most Recent job description
Household Income

If making less than 138% of federal poverty limit, I agree I am looking for a job making more than that

Other insurance

Do you have other insurance through work, VA benefits, healthcare.gov, medicare, etc? If you have other insurance, we can not enroll you in a plan

Other insurance

Do you have other insurance through work, VA benefits, healthcare.gov, medicare, etc?
If you have other insurance, we can not enroll you in a plan

Yes

Other taxable dependents in the household?
In addition to yourself, how many other people are in your taxable household that
DON’T need insurance. Please provide their full name, date of birth and relationship to you

How many other people are in your taxable household

Household Member Details.

Please provide their full name, date of birth and relationship to you

Info to help us choose the best plan for you

IF you want a specific plan or insurance carrier mention it here or anything else that we may need to know to help you.

Info to help us choose the best plan for you

IF you want a specific plan or insurance carrier mention it here or anything else that we may need to know to help you.

Robots can’t get insurance! What is 5+3=

Date

Signature

Sign Here

Signature

Sign Here

Yes! I give permission to apply for free health insurance

I confirm that the information provided above is true and accurate to the best of my knowledge.

Yes! I give permission to apply for free health insurance

I confirm that the information provided above is true and accurate to the best of my knowledge.

Straight to the form

Yes

Enroll Now

Complete the form below to obtain LOW to NO Cost Health Insurance.

First Name

Last Name

Date of Birth

Address

Address Line 1

Address Line 2

Phone/Mobile

Gender

Male

Female

Most Recent job description

Household Income

If making less than 138% of federal poverty limit, I agree I am looking for a job making more than that

Other insurance

Do you have other insurance through work, VA benefits, healthcare.gov, medicare, etc? If you have other insurance, we can not enroll you in a plan

Yes

Qualifying Event

Which qualifying event has occurred for you to enroll in special enrollment?

What date is/will this event happen? (what date will your health coverage be cancelled)

Social security number to verify citizenship

we can’t submit your application without your SSN. If you leave it blank we will send text reminders for you to call in your social security number on a recorded line.

if SSN isn’t valid, we will not submit the application for insurance & you will not have coverage

2nd person needing insurance

First Name

Last Name

2nd person’s gender

Male

Female

2nd persons Date of Birth

2nd persons social security number

you have 90 days to submit their SSN, if you do not the government will cancel your insurance

Relationship to 1st person How many people need coverage? (Select 3–5 if applicable)

Relationship to 1st person

Relationship to 2st person

Relationship to 1st person

Relationship to 2st person

Relationship to 3st person

Relationship to 1st person

Relationship to 2st person

Relationship to 3st person

Relationship to 4st person

Relationship to 1st person

Relationship to 2st person

Relationship to 3st person

Relationship to 4st person

Relationship to 5st person

Other taxable dependents in the household?

In addition to yourself, how many other people are in your taxable household that do NOT need insurance. Please provide their full name, date of birth and relationship to you

How many other people are in your taxable household

Household Member Details.

Please provide their full name, date of birth and relationship to you

Info to help us choose the best plan for you

IF you want a specific plan or insurance carrier mention it here or anything else that we may need to know to help you.

Robots can’t get insurance! What is 5+3=

Yes! I give permission to apply for free health insurance

I confirm that the information provided above is true and accurate to the best of my knowledge.

Date

Signature

Sign Here

Who is myObamacare?

Are You Ready to Gain a Peace of Mind?

Your search for affordable and accessible healthcare stops here at myObamacare.