Online Application

Easy Online Application For Quick & Easy Enrollment
Affordable Plans with Exclusive Benefits
4 Out 5 People Get $10 or less Premiums Without Any Hassle

Easy Online Application For Quick & Easy Enrollment
Affordable Plans with Exclusive Benefits
4 Out 5 People Get $10 or less Premiums Without Any Hassle

Register for INSTANT ACCESS to the TFRA Webinar

First Name *

Last Name *

City *

State *

Email *

Phone *

Date of birth *

Captcha

I agree to terms & conditions and privacy policy provided by the company. By providing my phone number, I agree to receive text messages from the business.

**Obtain Affordable Health Insurance through the**

Subsidized Marketplace in Texas today!

Complete the Texas survey for personalized insurance options and be sure to check your email (including spam) for important updates from us!

Let's Start with Basic Info

First Name *

Last Name *

Gender *

Male
Female
No elements found. Consider changing the search query.
List is empty.

Date of birth *

Email *

Phone *

Address (NO PO BOX's)*

City *

Postal code *

Marital Stauts *

Single
Married
Widowed
Separated
Divorced
No elements found. Consider changing the search query.
List is empty.

Spouse's Name *

Spouse's DOB *

Spouse's Employment *

Employed
Unemployed
Social Security Benefits
No elements found. Consider changing the search query.
List is empty.

Spouse's Estimated Annual Income - If any *

Spouse's Employer Name *

Do you want your Spouse covered on this policy? *

Yes

Spouse's Social Security Number *

Your current employment status? *

Employed

Unemployed

Receiving Social Security

Medicaid Health

Employer Name *

Approximate Annual Income *

Please provide an ESTIMATE of your income from all sources for the year. *

Monthly Social Security Income *

Are you enrolled in any of these plans? *

Medicare

Medicaid

None

Do you have children you claim on your taxes? *

Yes

First child's first and last name *

Child's DOB *

First child's Social Security Number

Do you have a second child? *

Yes

Second child's first and last name *

Second child's DOB *

Second child's Social Security Number

Do you have a third Child? *

Yes

Third child's first and last name *

Third child's DOB *

Third child's Social Security Number

Do you have a fourth Child? *

Yes

Fourth child's first and last name *

Fourth child's DOB *

Fourth child's Social Security Number

Do you have a primary care doctor you see regularly? *

Yes

Please list any Doctors' that YOU WANT TO KEEP and the location you see them. *

Do you take any medications currently? *

Yes

Please list all medications and dosages that you are currently talking. *

Are you a smoker? *

Yes

Do you also need a dental plan? *

Yes

What type of work do you need your dental plan to cover? *

Need Work Done
Just Preventative Cleanings
No elements found. Consider changing the search query.
List is empty.

Do you need a Vision Plan? *

Yes

How often do you need new glasses/contacts? *

Every Year
Every 2 Year
Not At All
No elements found. Consider changing the search query.
List is empty.

Do you need life insurance? *

Yes

Social Security Number (9 Digits) *

A Full 9 Digit Social is Required to Qualify

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Attestations

By clicking on this box and submitting this form, I agree to the following:

Consent to Use and Share My Personal Information (PII)

I authorize Charles P. Taylor and its licensed agents to collect, access, use, store, and disclose my personally identifiable information (PII) to assist me with:

Comparing health insurance plans
Determining my eligibility for health coverage, advance premium tax credits (APTC), cost-sharing reductions (CSR), and Medicaid/FAMIS (if applicable)
Selecting and enrolling in a Qualified Health Plan (QHP) or other health program through the Health Insurance Marketplace
Submitting or updating an application for coverage or financial assistance
Following up on my application or account, including responding to Marketplace inquiries

I understand that this consent includes information for all individuals listed on the application and that I have their permission to provide their PII for this purpose.

Acknowledgement of Privacy Notice Statement

I confirm that I have received, read, and understood the Privacy Notice Statement provided by Charles P. Taylor. This statement explains:

What personal data is collected and why
Who may access or receive my information (e.g., Marketplace, CMS, carriers)
How my data will be protected and secured
That providing this information is voluntary, but necessary for enrollment assistance
How I can file a privacy complaint or revoke this consent at any time

I understand that I may request a copy of the Privacy Notice by email or view it online at:

http://www.charlesptaylor.com/privacy-notice

Consent to Communications

I agree to receive phone calls, emails, and text messages from Charles P. Taylor regarding my application, enrollment status, or related updates. Message and data rates may apply. I can opt out of text messaging at any time by replying STOP.

Agent of Record Authorization

I designate Charles P. Taylor and its licensed agents as my Agent of Record (AOR) for health insurance coverage. As my AOR, they are authorized to:

Act on my behalf with the Marketplace
Access and update my application
Assist with plan selection and enrollment
Provide ongoing support and maintenance for my health coverage

This designation will remain in effect until I revoke it in writing by email, phone, or postal mail.

Applicant Attestations

I attest that:

I am not currently enrolled in any other health insurance unless otherwise disclosed
No one on this application is currently incarcerated
I will file a federal tax return for the year 2025 (filed in 2026) and in future years as required to maintain eligibility for APTC
I understand that the IRS will compare my estimated income to my tax return and that I may owe or receive additional tax credits as a result
If any information I provided changes (such as income, address, or household size), I will update my application through the Marketplace or notify Charles P. Taylor to assist me
I understand that not all policies include additional benefits or rewards; eligibility for these varies by plan, location, and program availability

Revocation of Consent

I understand that I may revoke or change this consent at any time by:

Emailing: [email protected]
Calling: 804-465-7899

I acknowledge that revoking my consent may impact my ability to receive assistance or remain enrolled through the Marketplace.

Agreement & Signature

I confirm that I have read and understood this entire consent and attestation form, and all information I provided is true and accurate to the best of my knowledge.

Your signature *

Clear

Obtain Affordable Health Insurance through the Subsidized Marketplace in Texas today!

Complete the Texas survey for personalized insurance options and be sure to check your email (including spam) for important updates from us!

Let's Start with Basic Info

First Name *

Last Name *

Gender *

Male
Female
No elements found. Consider changing the search query.
List is empty.

Date of birth *

Email *

Phone *

Address (NO PO BOX's)*

City *

Postal code *

Marital Stauts *

Single
Married
Widowed
Separated
Divorced
No elements found. Consider changing the search query.
List is empty.

Spouse's Name *

Spouse's DOB *

Spouse's Employment *

Employed
Unemployed
Social Security Benefits
No elements found. Consider changing the search query.
List is empty.

Spouse's Estimated Annual Income - If any *

Spouse's Employer Name *

Do you want your Spouse covered on this policy? *

Yes

Spouse's Social Security Number *

Your current employment status? *

Employed

Unemployed

Receiving Social Security

Medicaid Health

Employer Name *

Approximate Annual Income *

Please provide an ESTIMATE of your income from all sources for the year. *

Monthly Social Security Income *

Are you enrolled in any of these plans? *

Medicare

Medicaid

None

Do you have children you claim on your taxes? *

Yes

First child's first and last name *

Child's DOB *

First child's Social Security Number

Do you have a second child? *

Yes

Second child's first and last name *

Second child's DOB *

Second child's Social Security Number

Do you have a third Child? *

Yes

Third child's first and last name *

Third child's DOB *

Third child's Social Security Number

Do you have a fourth Child? *

Yes

Fourth child's first and last name *

Fourth child's DOB *

Fourth child's Social Security Number

Do you have a primary care doctor you see regularly? *

Yes

Please list any Doctors' that YOU WANT TO KEEP and the location you see them. *

Do you take any medications currently? *

Yes

Please list all medications and dosages that you are currently talking. *

Are you a smoker? *

Yes

Do you also need a dental plan? *

Yes

What type of work do you need your dental plan to cover? *

Need Work Done
Just Preventative Cleanings
No elements found. Consider changing the search query.
List is empty.

Do you need a Vision Plan? *

Yes

How often do you need new glasses/contacts? *

Every Year
Every 2 Year
Not At All
No elements found. Consider changing the search query.
List is empty.

Do you need life insurance? *

Yes

Social Security Number (9 Digits) *

A Full 9 Digit Social is Required to Qualify

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Attestations

By clicking on this box and submitting this form, I agree to the following:

Consent to Use and Share My Personal Information (PII)

I authorize Charles P. Taylor and its licensed agents to collect, access, use, store, and disclose my personally identifiable information (PII) to assist me with:

Comparing health insurance plans
Determining my eligibility for health coverage, advance premium tax credits (APTC), cost-sharing reductions (CSR), and Medicaid/FAMIS (if applicable)
Selecting and enrolling in a Qualified Health Plan (QHP) or other health program through the Health Insurance Marketplace
Submitting or updating an application for coverage or financial assistance
Following up on my application or account, including responding to Marketplace inquiries

I understand that this consent includes information for all individuals listed on the application and that I have their permission to provide their PII for this purpose.

Acknowledgement of Privacy Notice Statement

I confirm that I have received, read, and understood the Privacy Notice Statement provided by Charles P. Taylor. This statement explains:

What personal data is collected and why
Who may access or receive my information (e.g., Marketplace, CMS, carriers)
How my data will be protected and secured
That providing this information is voluntary, but necessary for enrollment assistance
How I can file a privacy complaint or revoke this consent at any time

I understand that I may request a copy of the Privacy Notice by email or view it online at:

http://www.charlesptaylor.com/privacy-notice

Consent to Communications

Agent of Record Authorization

I designate Charles P. Taylor and its licensed agents as my Agent of Record (AOR) for health insurance coverage. As my AOR, they are authorized to:

Act on my behalf with the Marketplace
Access and update my application
Assist with plan selection and enrollment
Provide ongoing support and maintenance for my health coverage

This designation will remain in effect until I revoke it in writing by email, phone, or postal mail.

Applicant Attestations

I attest that:

I am not currently enrolled in any other health insurance unless otherwise disclosed
No one on this application is currently incarcerated
I will file a federal tax return for the year 2025 (filed in 2026) and in future years as required to maintain eligibility for APTC
I understand that the IRS will compare my estimated income to my tax return and that I may owe or receive additional tax credits as a result
If any information I provided changes (such as income, address, or household size), I will update my application through the Marketplace or notify Charles P. Taylor to assist me
I understand that not all policies include additional benefits or rewards; eligibility for these varies by plan, location, and program availability

Revocation of Consent

I understand that I may revoke or change this consent at any time by:

Emailing: [email protected]
Calling: 804-465-7899

I acknowledge that revoking my consent may impact my ability to receive assistance or remain enrolled through the Marketplace.

Agreement & Signature

I confirm that I have read and understood this entire consent and attestation form, and all information I provided is true and accurate to the best of my knowledge.

Your signature *

Clear

No calls, no hassle—just chat with our Agents.

Each application needs to be filled out completely and double verified after you choose your plan. A licensed agent will then communicate with you about any additional information they need. The day the plan is written and approved you will receive a text message with a copy of the plan, link to look up additional Doctors and Drugs, and a link to that carrier’s rewards program.

This will be followed up by an email from www.healthcare.gov as well as receiving all information and appropriate cards in the mail in 3-4 weeks. You are all set.

How it works

No calls, no hassle—just chat with our Agents.

Each application needs to be filled out completely and double verified after you choose your plan. A licensed agent will then communicate with you about any additional information they need. The day the plan is written and approved you will receive a text message with a copy of the plan, link to look up additional Doctors and Drugs, and a link to that carrier’s rewards program.

This will be followed up by an email from www.healthcare.gov as well as receiving all information and appropriate cards in the mail in 3-4 weeks. You are all set.

Our motive is to make enrollment process easy. And enroll you in $10 or less premium which is depend on your annual household income & state of residence. 4 out of 5 people qualify for $10 or less Premium

Let's start your enrollment Process Now.