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Tell us a bit about yourself.

First Name *

Last Name *

Date of birth *

Email *

Phone *

Address *

City *

State *

Postal code *

Just a few more details about you.

What is Your Gender?

Please Select Your Marital Status

Married

Single

Separated

Divorced

Widowed

Primary Applicant Social Security Number

Additional Applicant Information

Full Name of Additional Applicant

Date of Birth of Additional Applicant

Employment Status

Employed

Self-employed

Unemployed

Gender of Additional Applicant

Male

Female

Income Source

Employed

Self Employed

Other Employment

Not Employed

What is your annual income?

$0 - $20,000

$20,001 - $40,000

$40,001 - $60,000

$60,001+

Employer Name

Do You Have Tax Dependents? (Typically Children)

Yes

Current Insurance Carrier

Current Insurance Plan

Do you or anyone in your household applying for coverage currently have Medicare, Medicaid, or VA?

Yes, Medicare

Yes, Medicaid

Yes, Both Medicare and Medicaid

Yes, VA Coverage

No Coverage

If you have Medicaid, will your Medicaid end soon?

Yes

Who is your primary care provider?

What is your choice of hospital to attend in event of an emergency?

Please list any specialists that oversee your care or you visit on a regular basis?

Please provide all current prescriptions and dosages.

Do you need extra dental coverage?

Yes, I would like information

No, not at this time

Would you like a quote on burial insurance?

Yes, I would like information

No, not at this time

I certify that I will be making the minimum income required for the subsidized healthcare based on the chart.

I Agree

I understand that if I am currently enrolled in a health insurance plan through the ACA or Marketplace, and this plan is not the most suitable option based on my specific needs, coverage requirements, or eligibility criteria, the agent has my consent to explore and enroll me in alternative health insurance plans offered by other carriers.

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Non-Marketing Consent Opt-In

I consent to receive non-marketing text messages from Lordes Insurance Group LLC about my insurance, appointment reminders, etc. Message & data rates may apply.

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Licensed in the following states: Louisiana,Mississippi, Texas, Georgia, Florida, Alabama, California, Arkansas

National Producer Number for David L Cantrelle Jr: 16447256

Lordes Insurance Group is NOT AFFILIATED with any Government Agency.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-Medicare, or your local state health insurance program, (SHIP) to get more information on your options.

(985) 503-0214