{"id":5966,"date":"2024-08-21T11:46:09","date_gmt":"2024-08-21T17:46:09","guid":{"rendered":"https:\/\/bestpolicy.co\/?page_id=5966"},"modified":"2024-08-21T11:50:42","modified_gmt":"2024-08-21T17:50:42","slug":"aca-quick-jobs","status":"publish","type":"page","link":"https:\/\/developer.bestpolicy.co\/es\/aca-quick-jobs\/","title":{"rendered":"ACA form QuickJobs"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"5966\" class=\"elementor elementor-5966\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6a0c32a2 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6a0c32a2\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-2d2b57d7\" data-id=\"2d2b57d7\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-08e4f0b elementor-widget elementor-widget-shortcode\" data-id=\"08e4f0b\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_42' style='display:none'><div id='gf_42' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_42'  action='\/es\/wp-json\/wp\/v2\/pages\/5966#gf_42' data-formid='42' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/5966#gf_42\">\n        <div id='gf_progressbar_wrapper_42' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>2<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_42_1' class='gform_page' data-js='page-field-id-0' >\n                                    <div class='gform_page_fields'><div id='gform_fields_42' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_42_217\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_217\" ><div class='ginput_container ginput_container_text'><input name='input_217' id='input_42_217' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_42_216\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_216\" ><h2>\u00bfTiene derecho a un seguro de enfermedad gratuito?<\/h2><\/div><div id=\"field_42_126\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_126\" ><!-- TrustedForm -->\n<script type=\"text\/javascript\">\n(function() {\nvar tf = document.createElement('script');\ntf.type = 'text\/javascript'; tf.async = true;\ntf.src = (\"https:\" == document.location.protocol ? 'https' : 'http') + \":\/\/api.trustedform.com\/trustedform.js?field=xxTrustedFormCertUrl&ping_field=xxTrustedFormPingUrl&l=\" + new Date().getTime() + Math.random();\n\nvar s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(tf, s);\n})();\n\n \n<\/script>\n<noscript>\n<img decoding=\"async\" src=\"https:\/\/api.trustedform.com\/ns.gif\" \/>\n<\/noscript>\n<!-- End TrustedForm -->\n<\/div><fieldset id=\"field_42_56\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_56\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Doy permiso a Best Policy, LLC, My Health Insurance, LLC, e Insurely, LLC y sus afiliados para acceder y\/o crear mi solicitud de seguro de salud en el Mercado Facilitado Federalmente (FFM) basado en la informaci\u00f3n que estoy proporcionando a continuaci\u00f3n. Tambi\u00e9n les doy mi consentimiento para que se comuniquen conmigo a trav\u00e9s de: Correo electr\u00f3nico, SMS o por tel\u00e9fono.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_42_56'><div class='gchoice gchoice_42_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='Yes, I give Permission.'  id='choice_42_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_56_1' id='label_42_56_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed, doy permiso.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_42_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full radio-same-line gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_55\" ><legend class='gfield_label gform-field-label' >Do you currently have any form of health insurance? Including insurance through your employer, Medicare, Medicaid or VA?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_42_55'>\n\t\t\t<div class='gchoice gchoice_42_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_42_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_42_55_0' id='label_42_55_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_42_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_42_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_42_55_1' id='label_42_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_42_32\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_32\" ><legend class='gfield_label gform-field-label' >Solicitante principal Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_42_32' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_42_32_1_container'><label for='input_42_32_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mes<\/label><select name='input_32[]' id='input_42_32_1'   aria-required='true'  ><option value=''>Mes<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_42_32_2_container'><label for='input_42_32_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>D\u00eda<\/label><select name='input_32[]' id='input_42_32_2'   aria-required='true'  ><option value=''>D\u00eda<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_42_32_3_container'><label for='input_42_32_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>A\u00f1o<\/label><select name='input_32[]' id='input_42_32_3'   aria-required='true'  ><option value=''>A\u00f1o<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_42_146\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_146\" ><\/div><\/div><div id=\"field_42_147\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_147\" ><div><\/div><fieldset id=\"field_42_13\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_13\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Su nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_42_13'>\n                            \n                            <span id='input_42_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_42_13_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                    <label for='input_42_13_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_42_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_42_13_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                    <label for='input_42_13_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_42_218\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_218\" ><label class='gfield_label gform-field-label' for='input_42_218'>Tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_218' id='input_42_218' type='text' value='' class='large'  aria-describedby=\"gfield_description_42_218\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_42_218'>Please input your phone in the following format (801) 805-4555<\/div><\/div><div id=\"field_42_15\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_15\" ><label class='gfield_label gform-field-label' for='input_42_15'>Correo electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_15' id='input_42_15' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                        <\/div><\/div><fieldset id=\"field_42_16\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_16\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_42_16' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_42_16_1_container' >\n                                        <label for='input_42_16_1' id='input_42_16_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                        <input type='text' name='input_16.1' id='input_42_16_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_42_16_2_container' >\n                                        <label for='input_42_16_2' id='input_42_16_2_label' class='gform-field-label gform-field-label--type-sub'>Address Line 2<\/label>\n                                        <input type='text' name='input_16.2' id='input_42_16_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_42_16_3_container' >\n                                    <label for='input_42_16_3' id='input_42_16_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                    <input type='text' name='input_16.3' id='input_42_16_3' value=''    aria-required='true'    \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_16.4' id='input_42_16_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_42_16_5_container' >\n                                    <label for='input_42_16_5' id='input_42_16_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_16.5' id='input_42_16_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_16.6' id='input_42_16_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_42_155\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_155\" ><div><\/div><div id=\"field_42_76\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half state field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_76\" ><label class='gfield_label gform-field-label' for='input_42_76'>Seleccionar Estado<\/label><div class='ginput_container ginput_container_select'><select name='input_76' id='input_42_76' class='large gfield_select'     aria-invalid=\"false\" ><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >Distrito de Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawai<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Luisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >Nuevo Hampshire<\/option><option value='New Jersey' >Nueva Jersey<\/option><option value='New Mexico' >Nuevo M\u00e9xico<\/option><option value='New York' >Nueva York<\/option><option value='North Carolina' >Carolina del Norte<\/option><option value='North Dakota' >Dakota del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oreg\u00f3n<\/option><option value='Pennsylvania' >Pensilvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >Carolina del Sur<\/option><option value='South Dakota' >Dakota del Sur<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >Virginia Occidental<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><\/select><\/div><\/div><div id=\"field_42_179\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_179\" ><label class='gfield_label gform-field-label' for='input_42_179'>What is Most Important to You?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_179' id='input_42_179' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='A. $0 Premium' selected='selected'>A. $0 Premium<\/option><option value='B. Doctors in Network' >B. Doctors in Network<\/option><option value='C. Doctors Close By' >C. Doctors Close By<\/option><option value='D. Medication Costs' >D. Medication Costs<\/option><option value='E. Other: Please Specify in Note Box Below' >E. Other: Please Specify in Note Box Below<\/option><\/select><\/div><\/div><div id=\"field_42_156\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_156\" ><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_42_213' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_42_2' class='gform_page' data-js='page-field-id-213' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_42_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_42_125\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_125\" ><b>Bas\u00e1ndonos en la informaci\u00f3n que has compartido, hemos encontrado estos transportistas que tienen planes de coste cero. <\/b><\/div><fieldset id=\"field_42_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_123\" ><legend class='gfield_label gform-field-label' >\u00bfQu\u00e9 compa\u00f1\u00eda a\u00e9rea le interesa?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_42_123'>\n\t\t\t<div class='gchoice gchoice_42_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value=''  id='choice_42_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_42_123_0' id='label_42_123_0' class='gform-field-label gform-field-label--type-inline'><\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_42_208\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_208\" ><legend class='gfield_label gform-field-label' >Selecci\u00f3n de planes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_42_208'>\n\t\t\t<div class='gchoice gchoice_42_208_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_208' type='radio' value=''  id='choice_42_208_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_42_208_0' id='label_42_208_0' class='gform-field-label gform-field-label--type-inline'><\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_206\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_206\" ><\/br><\/div><div id=\"field_42_121\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_121\" ><label class='gfield_label gform-field-label' for='input_42_121'>Notes:<\/label><div class='gfield_description' id='gfield_description_42_121'>Doctors, medications or any other information you\u2019d like us to know about your health insurance enrollment?<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_121' id='input_42_121' class='textarea large'  aria-describedby=\"gfield_description_42_121\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_42_164\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_164\" ><div><\/div><div id=\"field_42_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_21\" ><label class='gfield_label gform-field-label' for='input_42_21'>N\u00famero de la Seguridad Social<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_42_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_42_26\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_26\" ><label class='gfield_label gform-field-label' for='input_42_26'>G\u00e9nero<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_42_26' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='male' >Hombre<\/option><option value='female' >Mujer<\/option><\/select><\/div><\/div><div data-fieldid=\"26\" class=\"spacer gfield\" style=\"grid-column: span 6;\" data-groupid=\"3b8cacb5\"><\/div><div id=\"field_42_165\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_165\" ><\/div><\/div><fieldset id=\"field_42_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full radio-same-line gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_67\" ><legend class='gfield_label gform-field-label' >Situaci\u00f3n fiscal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_42_67'>\n\t\t\t<div class='gchoice gchoice_42_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Single'  id='choice_42_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_42_67_0' id='label_42_67_0' class='gform-field-label gform-field-label--type-inline'>\u00danico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_42_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Yes'  id='choice_42_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_42_67_1' id='label_42_67_1' class='gform-field-label gform-field-label--type-inline'>Casado que presenta una declaraci\u00f3n conjunta (las parejas casadas deben presentar una declaraci\u00f3n conjunta para tener derecho a la ayuda)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_42_67_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Head of Household'  id='choice_42_67_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_42_67_2' id='label_42_67_2' class='gform-field-label gform-field-label--type-inline'>Head of Household<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_100\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_100\" ><label class='gfield_label gform-field-label' for='input_42_100'>Nombre del c\u00f3nyuge<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_42_100' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_42_106\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_106\" ><label class='gfield_label gform-field-label' for='input_42_106'>C\u00f3nyuge Apellido<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_42_106' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_42_107\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_107\" ><label class='gfield_label gform-field-label' for='input_42_107'>Fecha de nacimiento<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_107' id='input_42_107' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_42_107_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_42_107_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_42_107' class='gform_hidden' value='https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_42_109\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_109\" ><label class='gfield_label gform-field-label' for='input_42_109'>G\u00e9nero<\/label><div class='ginput_container ginput_container_select'><select name='input_109' id='input_42_109' class='large gfield_select'     aria-invalid=\"false\" ><option value='Male' >Hombre<\/option><option value='Female' >Mujer<\/option><\/select><\/div><\/div><div id=\"field_42_110\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_110\" ><label class='gfield_label gform-field-label' for='input_42_110'>N\u00famero de la Seguridad Social del c\u00f3nyuge<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_42_110' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_42_111\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_111\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento del c\u00f3nyuge<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_42_111'><div class='gchoice gchoice_42_111_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_111.1' type='checkbox'  value='Please add this Dependant to my health insurance policy'  id='choice_42_111_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_111_1' id='label_42_111_1' class='gform-field-label gform-field-label--type-inline'>Por favor, a\u00f1ada a esta persona a mi p\u00f3liza de seguro de enfermedad<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_112\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_112\" ><\/br><\/div><fieldset id=\"field_42_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full radio-same-line gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_71\" ><legend class='gfield_label gform-field-label' >Will you be claiming any dependents on your taxes in 2024?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_42_71'>\n\t\t\t<div class='gchoice gchoice_42_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_42_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_42_71_0' id='label_42_71_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_42_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_42_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_42_71_1' id='label_42_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_130\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_130\" ><label class='gfield_label gform-field-label' for='input_42_130'>Nombre de la persona a cargo 1<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_42_130' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_42_132\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_132\" ><label class='gfield_label gform-field-label' for='input_42_132'>Dependiente 1 Apellido<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_42_132' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_42_137\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_137\" ><label class='gfield_label gform-field-label' for='input_42_137'>Dependiente 1 Fecha de nacimiento<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_137' id='input_42_137' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_42_137_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_42_137_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_42_137' class='gform_hidden' value='https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_42_134\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_134\" ><label class='gfield_label gform-field-label' for='input_42_134'>Dependiente 1 Sexo<\/label><div class='ginput_container ginput_container_select'><select name='input_134' id='input_42_134' class='medium gfield_select'     aria-invalid=\"false\" ><option value='male' >Hombre<\/option><option value='female' >Mujer<\/option><\/select><\/div><\/div><div id=\"field_42_136\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_136\" ><label class='gfield_label gform-field-label' for='input_42_136'>Dependiente 1 N\u00famero de la Seguridad Social<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_42_136' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_42_135\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_135\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dependiente 1 Consentimiento<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_42_135'><div class='gchoice gchoice_42_135_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_135.1' type='checkbox'  value='Please add this Dependant to my health insurance policy'  id='choice_42_135_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_135_1' id='label_42_135_1' class='gform-field-label gform-field-label--type-inline'>Por favor, a\u00f1ada a esta persona a mi p\u00f3liza de seguro de enfermedad<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_104\" class=\"gfield gfield--type-slider gfield--input-type-slider gfield--width-seven-twelfths range field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_104\" ><label class='gfield_label gform-field-label' for='input_42_104'>Please select the value closest to your estimated 2024 income*<\/label><div class='ginput_container ginput_container_slider'><input name='input_104' id='input_42_104' type='text' step='1000' min='14,500' max='150,000' data-value-visibility='show' data-connect=\"false\" value='82' class='slider large' data-min-relation='' data-max-relation='' data-value-format='currency' data-currency='{\"name\":\"U.S. Dollar\",\"symbol_left\":\"$\",\"symbol_right\":\"\",\"symbol_padding\":\"\",\"thousand_separator\":\",\",\"decimal_separator\":\".\",\"decimals\":2,\"code\":\"USD\"}'    \/><div id='gsfslider_104' class='slider-display gform-theme__disable-reset'><\/div><\/div><\/div><fieldset id=\"field_42_61\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full bg-white consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_61\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Verificaci\u00f3n de ingresos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_42_61'>By clicking the checkbox below, I hereby provide consent and authorization to My Health Insurance, LLC and Best Policy, LLC and\/or its affiliates to submit my estimated income within a range of 20% above or below the estimated income that I provided on this application. I also provide consent and authorization to My Health Insurance, LLC and Best Policy, LLC  and\/or its affiliates to submit an income verification letter on my behalf if required by the marketplace.<\/div><div class='ginput_container ginput_container_consent'><input name='input_61.1' id='input_42_61_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_42_61\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_42_61_1' >S\u00ed, estoy de acuerdo<\/label><input type='hidden' name='input_61.2' value='Yes, I Agree' class='gform_hidden' \/><input type='hidden' name='input_61.3' value='39' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_42_194\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_194\" ><\/br><\/div><div id=\"field_42_187\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_187\" >\u00bfAlg\u00fan cambio en los \u00faltimos 60 d\u00edas o pr\u00f3xima p\u00e9rdida de cobertura?<\/div><fieldset id=\"field_42_180\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_180\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cobertura de p\u00e9rdidas<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_42_180'><div class='gchoice gchoice_42_180_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.1' type='checkbox'  value='Loss Coverage'  id='choice_42_180_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_180_1' id='label_42_180_1' class='gform-field-label gform-field-label--type-inline'>A. Loss Coverage<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_195\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_195\" ><hr style=\"    width: 50%;\"\/><\/div><fieldset id=\"field_42_188\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-quarter field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_188\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Loss Coverage options<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_42_188'><div class='gchoice gchoice_42_188_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.1' type='checkbox'  value='Medicare'  id='choice_42_188_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_188_1' id='label_42_188_1' class='gform-field-label gform-field-label--type-inline'>Medicare<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_42_188_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.2' type='checkbox'  value='Medicaid\/CHIP'  id='choice_42_188_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_188_2' id='label_42_188_2' class='gform-field-label gform-field-label--type-inline'>Medicaid\/CHIP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_42_188_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.3' type='checkbox'  value='Employer Plan'  id='choice_42_188_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_188_3' id='label_42_188_3' class='gform-field-label gform-field-label--type-inline'>Plan de empresa<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_42_188_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_188.4' type='checkbox'  value='Other'  id='choice_42_188_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_188_4' id='label_42_188_4' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_183\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_183\" ><label class='gfield_label gform-field-label' for='input_42_183'>Otros:<\/label><div class='ginput_container ginput_container_text'><input name='input_183' id='input_42_183' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_42_198\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_198\" ><label class='gfield_label gform-field-label' for='input_42_198'>Cobertura de p\u00e9rdidas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_198' id='input_42_198' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_42_198_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_42_198_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_42_198' class='gform_hidden' value='https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_42_197\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_197\" ><hr style=\"    width: 50%;\"\/><\/div><fieldset id=\"field_42_181\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_181\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >B. Puesta en libertad<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_42_181'><div class='gchoice gchoice_42_181_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.1' type='checkbox'  value='Release from incarceration'  id='choice_42_181_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_181_1' id='label_42_181_1' class='gform-field-label gform-field-label--type-inline'>B. Puesta en libertad<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_190\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_190\" ><label class='gfield_label gform-field-label' for='input_42_190'>Release from incarceration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_190' id='input_42_190' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_42_190_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_42_190_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_42_190' class='gform_hidden' value='https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_42_184\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_184\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >C. Moved<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_42_184'><div class='gchoice gchoice_42_184_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_184.1' type='checkbox'  value='Moved'  id='choice_42_184_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_184_1' id='label_42_184_1' class='gform-field-label gform-field-label--type-inline'>C. Moved<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_192\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_192\" ><label class='gfield_label gform-field-label' for='input_42_192'>Moved<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_192' id='input_42_192' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_42_192_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_42_192_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_42_192' class='gform_hidden' value='https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_42_185\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_185\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >D. Change in marital status<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_42_185'><div class='gchoice gchoice_42_185_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_185.1' type='checkbox'  value='Change in marital status'  id='choice_42_185_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_185_1' id='label_42_185_1' class='gform-field-label gform-field-label--type-inline'>D. Change in marital status<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_196\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-third gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_196\" ><hr style=\"    width: 50%;\" ><\/div><fieldset id=\"field_42_189\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_189\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >D. Change in marital status Options<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_42_189'><div class='gchoice gchoice_42_189_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_189.1' type='checkbox'  value='Divorce'  id='choice_42_189_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_189_1' id='label_42_189_1' class='gform-field-label gform-field-label--type-inline'>Divorce<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_42_189_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_189.2' type='checkbox'  value='Widowed'  id='choice_42_189_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_189_2' id='label_42_189_2' class='gform-field-label gform-field-label--type-inline'>Widowed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_42_189_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_189.3' type='checkbox'  value='Separated'  id='choice_42_189_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_189_3' id='label_42_189_3' class='gform-field-label gform-field-label--type-inline'>Separated<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_191\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_191\" ><label class='gfield_label gform-field-label' for='input_42_191'>Change in marital status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_191' id='input_42_191' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_42_191_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_42_191_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_42_191' class='gform_hidden' value='https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_42_167\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_167\" ><\/br> <\/div><fieldset id=\"field_42_129\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_129\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are you interested in our licensed representative reaching out to you regarding Dental, Vision or Supplemental insurance?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_42_129'><div class='gchoice gchoice_42_129_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.1' type='checkbox'  value='Dental'  id='choice_42_129_1'   aria-describedby=\"gfield_description_42_129\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_42_129_1' id='label_42_129_1' class='gform-field-label gform-field-label--type-inline'>Dental<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_42_129_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.2' type='checkbox'  value='Vision'  id='choice_42_129_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_129_2' id='label_42_129_2' class='gform-field-label gform-field-label--type-inline'>Vision<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_42_129_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.3' type='checkbox'  value='Supplemental insurance'  id='choice_42_129_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_129_3' id='label_42_129_3' class='gform-field-label gform-field-label--type-inline'>Supplemental insurance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_42_129_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.4' type='checkbox'  value='Life Insurance'  id='choice_42_129_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_129_4' id='label_42_129_4' class='gform-field-label gform-field-label--type-inline'>Life Insurance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_42_129_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.5' type='checkbox'  value='Auto insurance'  id='choice_42_129_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_129_5' id='label_42_129_5' class='gform-field-label gform-field-label--type-inline'>Auto insurance<\/label>\n\t\t\t\t\t\t\t<\/div><button type=\"button\" id=\"button_129_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Select All\" data-label-deselect=\"Deselect All\">Select All<\/button><\/div><\/div><div class='gfield_description' id='gfield_description_42_129'>Supplemental insurance is a type of insurance policy that helps cover costs not covered by primary health insurance. It provides additional benefits to policyholders to help offset expenses such as deductibles, copayments, and coinsurance.\n\nWe will contact you after your application is submited to discuss the option selected above. <\/div><\/fieldset><div id=\"field_42_168\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_168\" ><\/br><\/div><fieldset id=\"field_42_138\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_138\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How should we contact you?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_42_138'><div class='gchoice gchoice_42_138_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_138.1' type='checkbox'  value='Call'  id='choice_42_138_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_138_1' id='label_42_138_1' class='gform-field-label gform-field-label--type-inline'>Call<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_42_138_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_138.2' type='checkbox'  value='Text \/ SMS'  id='choice_42_138_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_138_2' id='label_42_138_2' class='gform-field-label gform-field-label--type-inline'>Text \/ SMS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_42_138_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_138.3' type='checkbox'  value='Email'  id='choice_42_138_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_42_138_3' id='label_42_138_3' class='gform-field-label gform-field-label--type-inline'>Correo electr\u00f3nico<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_42_202\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_202\" ><\/br><\/div><div id=\"field_42_141\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_141\" ><\/div><fieldset id=\"field_42_139\" class=\"gfield gfield--type-time gfield--input-type-time gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_139\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Time<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_42_139'>\n                            <input type='number' maxlength='2' name='input_139[]' id='input_42_139_1' value='05'  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_42_139_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_139[]' id='input_42_139_2' value='00'  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_42_139_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_139[]' id='input_42_139_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' selected='selected'>PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_42_139_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_42_169\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_169\" ><\/br><\/div><fieldset id=\"field_42_105\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full bg-white consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_105\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent Acknowledgement<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_42_105'>By clicking \u201cI Agree\u201d, I am providing my electronic signature expressly authorizing My Health Insurance, LLC and Best Policy, LLC and\/or its affiliate to contact me by email, phone or text (including an automatic dialing system or artificial\/pre-recorded voice) at the home or cell phone number above. I understand I am not required to sign\/agree to this as a condition to purchase. I give my permission to My Health Insurance, LLC and Best Policy, LLC and\/or its affiliates to serve as the health insurance agency, agent, and\/or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned agency, agent, and\/or broker to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: 1- Searching for an existing Marketplace application; 2- Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums; 3- Providing ongoing account maintenance and enrollment assistance, as necessary; or 4- Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the agency, agent, and\/or broker will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agency, agent, and\/or broker will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provided for entry on my Marketplace eligibility and enrollment application is true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agency, agent, and\/or broker beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by emailing privacy@myhealthinsurance.ai<\/div><div class='ginput_container ginput_container_consent'><input name='input_105.1' id='input_42_105_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_42_105\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_42_105_1' >S\u00ed, estoy de acuerdo<\/label><input type='hidden' name='input_105.2' value='Yes, I Agree' class='gform_hidden' \/><input type='hidden' name='input_105.3' value='39' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_42_200\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_200\" ><\/br><\/div><div id=\"field_42_201\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_201\" ><\/br><\/div><fieldset id=\"field_42_64\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full bg-white consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_64\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent to Enrollment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_42_64'>Disclaimer for Health Insurance Applications<br \/>\nPlease note that due to circumstances beyond our control, we cannot guarantee the processing time for your application. However, we strive to handle your application as promptly as possible. If we require further clarification or additional information, one of our knowledgeable agents will contact you using the method you specified in your application.<br \/>\nWe are committed to meeting your healthcare and ancillary insurance needs and aim to become the agency you are proud to recommend to your family and friends. If a prompt submission of your application is necessary or you have any questions before submitting your application, please contact us at 385-308-5251 (available from 9 AM to 9 PM Eastern) or via email at Info@BestPolicy.co.<\/div><div class='ginput_container ginput_container_consent'><input name='input_64.1' id='input_42_64_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_42_64\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_42_64_1' >S\u00ed, estoy de acuerdo<\/label><input type='hidden' name='input_64.2' value='Yes, I Agree' class='gform_hidden' \/><input type='hidden' name='input_64.3' value='39' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_42_204\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_204\" ><\/br><\/div><div id=\"field_42_193\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_193\" ><label class='gfield_label gform-field-label' for='input_42_193'>Consent Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_42_193_Container' class='gfield_signature_container ginput_container' style='height:180px; width:523px; ' ><input type='hidden' class='gform_hidden' name='input_42_193_valid' id='input_42_193_valid' \/><canvas id='input_42_193' width='523' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_42_193_toolbar' style='margin:5px 0;position:relative;height:20px;width:523px;max-width:100%;'><img id = 'input_42_193_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' ><\/div><input type='hidden' id='input_42_193_data' name='input_42_193_data' value=''><\/div><\/div><div id=\"field_42_205\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full date-today gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_205\" ><script>\ndocument.addEventListener('DOMContentLoaded', function() {\n    \/\/ Replace FORMID and FIELDID with your form ID and field ID\n    var dateField = document.querySelector('#date-today-consent');\n    if (dateField) {\n        var today = new Date().toISOString().split('T')[0];\n        dateField.value = today;\n    }\n});\n<\/script>\n\n <input type=\"date\" id=\"date-today-consent\" disabled><\/div><div id=\"field_42_170\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_170\" ><\/br><\/div><fieldset id=\"field_42_65\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full bg-white consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_65\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Authorization and Tax attestation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_42_65'>If another agent goes into your application and changes the agent of record, we will no longer have access to your policy. Should that happen, do you give permission to our agency to go back in and be listed as agent of record?  | Renewal Authorization: Open Enrollment begins Nov 1st of every year. This is when we need to re-enroll your health policy with us. Do you authorize us to auto-renew your insurance policy and change your plan to a different company if needed to ensure your plan remains $0 even if there is a different network of doctors? This allows us to remain agent of record and ensure your coverage does not lapse. | Tax Attestation - Please confirm that you: (1) Agree to allow the Marketplace to use your income data, including information from tax returns, for the next 5 years; (2) understand that you are not eligible for a premium tax credit if found eligible for other qualifying health coverage, such as Medicaid, CHIP, or a job-based health plan; (3) understand that if you become eligible for other qualifying health coverage, you must contact the Marketplace to end your coverage and premium tax credit; (4) understand if the income on your tax return is higher than the amount of income on your application, you may owe additional federal income tax. I acknowledge that to participate in the Affordable Care Act program, I am required to file taxes for any year in which I have been enrolled. Failure to do so may result in loss of future eligibility<\/div><div class='ginput_container ginput_container_consent'><input name='input_65.1' id='input_42_65_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_42_65\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_42_65_1' >S\u00ed, estoy de acuerdo<\/label><input type='hidden' name='input_65.2' value='Yes, I Agree' class='gform_hidden' \/><input type='hidden' name='input_65.3' value='39' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_42_66\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full bg-white consent gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_42_66\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Verification of Information &amp; Submit Application<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_42_66'>I have reviewed the above application information and attest to its accuracy,  You agree that you have provided true answers to all of the questions to the best of your knowledge, and you know you may be subject to penalties under federal law if you intentionally provide false information. You attest that your estimated income for 2024 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. A Best Policy or My Health Insurance licensed agent will call you as we process your enrollment. 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