Clever Select Insurance

We can help you to find Marketplace health insurance as part of the Affordable Care Act

My experience with Clever Select Insurance has been one of the smoothest insurance experiences I have ever had. They got me great health coverage without spending hours on the phone.

Jennifer G

Phoenix, AZ

Carriers We Represent

... and many more!

Family Size	100%	150%	200%	400%
1	$14,580	$21,870	$29,160	$58,320
2	$19,720	$29,580	$39,440	$78,880
3	$24,860	$37,290	$49,720	$99,440
4	$30,000	$45,000	$60,000	$120,000
5	$35,140	$52,710	$70,280	$140,560
6	$40,280	$60,420	$80,560	$161,120
7	$45,420	$68,130	$90,840	$181,680
8	$50,560	$75,840	$101,120	$202,240
9	$55,700	$83,550	$111,400	$222,800
10	$60,840	$91,260	$121,680	$243,360

SEE IF YOU QUALIFY!

Please enable JavaScript in your browser to complete this form.

Are You Currently Employed?

Name of Employer

Do you have insurance through your employer, Medicaid or VA?

Layout

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Gender

Male
Female

Phone

Social Security #

Date of Birth

Spouse Name

Spouse Date of Birth

Spouse Social Security #

Layout

How Many People Need Coverage?

Expected Household Income Per Month

Please Be Accurate - Income Will Be Verified By Healthcare.gov

You attest that your estimated income for 2023 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.

In some cases, it may be necessary to verify your income. If income verification is required in order to complete your enrollment, do you authorize Clever Select Insurance to submit an income attestation letter on your behalf with the information that you have provided?

Consent to Enrollment; Verification of Information

By checking this box, I hereby provide consent and authorization to Clever Select Insurance, 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 Clever Select Insurance, LLC and it’s Agents 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 This consent will remain in effect unless and until rescinded by you in writing by emailing support@cleverselectinsurance.com.

Appointment of Clever Select Insurance, LLC as Authorized Representative / Power of Attorney:

DISCLOSURES REGARDING LIMITED POWER OF ATTORNEY

The following limited power of attorney authorizes Clever Select Insurance, LLC to make decisions concerning your health insurance. This limited power of attorney does not authorize Clever Select Insurance, LLC or any other person to make decisions about your medical care.

The following limited power of attorney becomes effective immediately upon signing. If Clever Select Insurance, LLC is unable or unwilling to act for you after you sign the limited power of attorney, we will notify you and this power of attorney will end.

Please review the limited power of attorney carefully. If you have questions about the power of attorney or the authority you are granting to Clever Select Insurance, LLC you should seek legal advice before signing this form.

FORM OF LIMITED POWER OF ATTORNEY

I grant Clever Select Insurance, LLC limited authority to take any and all actions to select, procure, and maintain health insurance for myself and any dependents though the Federally-Facilitated Marketplace ("FFM"), including, but not limited to the following actions:

    Select a health plan for me;
    Apply for and enroll me (and any dependents) in the selected health plan;
    Add or remove coverage;
    Create or change a beneficiary or dependent designation;
    Update contact information for me and any dependents or beneficiaries;
    Update information relevant to eligibility for subsidies for the health insurance;
    Submit supplemental materials to a health insurance marketplace or exchange, including, but not limited to, proof of income and social security numbers;
    Keep my health insurance in-force by renewing coverage from time to time;
    Change the health plan if a better plan is available; and
    Take any other action with regard to such health insurance as permitted by law.

The authority granted to Clever Select Insurance, LLC hereunder will cease upon my death, incapacity, or if I revoke the power of attorney in writing to Clever Select Insurance, LLC.

Any person, including, without limitation, Clever Select Insurance, LLC, any web-broker through which Clever Select Insurance, LLC may submit an application for insurance on my behalf, and the FFM, may rely upon the validity of this limited power of attorney or a copy of it unless that person knows it has been terminated.

Acknowledgements

By checking this box I provide my express consent to Clever Select Insurance, LLC. and grant Clever Select Insurance, LLC. and/or its agents a limited power of attorney to enroll me in a health insurance plan and to automatically enroll me in a plan at renewal.

Layout

I hereby signify my agreement with the foregoing by signing below

Clear Signature

Enter Today's Date

4 Out of 5 Of Our Customers Qualify for A
$0 Premium Health Insurance Policy

We can help you to find Marketplace health insurance as part of the Affordable Care Act

Carriers We Represent

... and many more!

HOW IT WORKS

SEE IF YOU QUALIFY!

Appointment of Clever Select Insurance, LLC as Authorized Representative / Power of Attorney:

4 Out of 5 Of Our Customers Qualify for A $0 Premium Health Insurance Policy

We can help you to find Marketplace health insurance as part of the Affordable Care Act

Carriers We Represent

... and many more!

HOW IT WORKS

SEE IF YOU QUALIFY!

Appointment of Clever Select Insurance, LLC as Authorized Representative / Power of Attorney:

4 Out of 5 Of Our Customers Qualify for A
$0 Premium Health Insurance Policy