Powerhouse Health Site

Health Insurance Plans for Everyone

Your Information

First Name

Last Name

Date of birth

Primary Applicant's Social Security Number

I don't have a SSN

I do not have a SSN

Home Address

Address

City

State

Postal code

Communication

Email *

Phone *

Written Language

Spoken Language

Are you Applying for Coverage?

Yes

No

Who Else is Applying for Coverage

Spouse

Dependent

Who else do you want the policy to cover? Please enter their information below.

Spouse

Full Name of Spouse

Date of Birth of Spouse

Do You Have Any Dependents?

Yes

No

Who else do you want the policy to cover? Please enter their information below.

Dependent 1 Full Legal Name

Dependent 1 Date of Birth MM-DD-YYYY

Dependent 1 Gender

Dependent 1 Social Security Number

Dependent 2 Full Legal Name

Dependent 2 Date of Birth MM-DD-YYYY

Dependent 2 Gender

Dependent 2 Social Security Number

Do You Have a 3rd Dependent?

Yes

No

Dependent 3 Full Legal Name

Dependent 3 Date of Birth MM-DD-YYYY

Dependent 3 Gender

Dependent 3 Social Security Number

Do You Have a 4th Dependent?

Yes

No

Dependent 4 Full Legal Name

Dependent 4 Date of Birth MM-DD-YYYY

Dependent 4 Gender

Dependent 4 Social Security Number

Do You Have a 5th Dependent?

Yes

No

Dependent 5 Full Legal Name

Dependent 5 Date of Birth MM-DD-YYYY

Dependent 5 Gender

Dependent 5 Social Security Number

Your Information

Have you used tobacco 4 or more times in a week in the past 6 months?

Yes

No

Are you currently incarcerated? (detained or jailed)?

Yes

No

Are you a US citizen ot US national?

Yes

No

What is your annual income?

$0 - $20,000

$20,000 - $40,000

$40,001 - $60,000

$60,001+

Employer Name and Phone Number

Additional Questions

Do any of the people in your household have a disability or mental health condition that limits their ability to work, attend school, or take care of their daily needs?

Do any of the people in your household need help with daily activities (like dressing or using the bathroom), or live in a medical facility or nursing home?

Were any of the people in your household found not eligible for Medicaid or the Children's Health Insurance Program in the past 90 days?

Did anyone in your household have Medicaid or CHIP coverage that will end soon ot that recently ended because of a change in eligibility?

Please click on Enrollment Consent Form below for review.

By providing my phone number, I agree to receive text messages from the business.

Authorization Signature *

Clear

We Actively Strive To Exceed Our

Customers' Expectations

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Peace of mind

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Set for life

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25

YEARS

Experience

Health Insurance Plans for Everyone

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Which Home Insurance

Is Right For You?

Travel Insurance

Life Insurance

Health Insurance

Car Insurance

Life Insurance

Our Team

John Doe

Frequently Asked Question

Your Title Here

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Client’s Give Us Many

Reviews For Us.

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jane Doe / Designer

Very helpful fully explaining the different plans. Cash value is accessed via policy loans, which accrue interest and reduce cash value our valuable items.

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John Doe / Designer

Very helpful fully explaining the different plans. Cash value is accessed via policy loans, which accrue interest and reduce cash value our valuable items.

300 +

Partners in the World

165 +

Awards Winmap 2

80K +

Satisfied Clients

100%

Success Rate

Post Address and Mail

Address

Office: Lorem Ipsum, XX, 12345

Email: [email protected]

Get In Touch

Assistance Hours

Mon – Sat 9:00am – 8:00pm

Sunday – CLOSED

Phone Number:

xxx-xxx-xxxx

Office: Lorem Ipsum

Call xxx-xxx-xxxx

Email:[email protected]

Site: www.yourcompany.com

Health Insurance Plans for Everyone

We Actively Strive To Exceed Our

Customers' Expectations

Tailored Cover​

Peace of mind

Set for life

Health Insurance Plans for Everyone

Which Home Insurance

Is Right For You?

Travel Insurance

Life Insurance

Life Insurance

Health Insurance

Car Insurance

Life Insurance

Our Team

John Doe

John Doe

John Doe

John Doe

Your Title Here

Your Title Here

Your Title Here

Client’s Give Us Many

Reviews For Us.

300 +

165 +

80K +

100%

Copyright 2022 . All rights reserved

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