planpurple.com Open in urlscan Pro
2606:4700:3034::6815:1e9  Public Scan

Form analysis
1 forms found in the DOM

POST review1.php?

<form id="mainform" action="review1.php?" method="POST">
  <input type="hidden" name="cid" value="">
  <input type="hidden" name="landing_page_url" value="http://planpurple.com/">
  <input type="hidden" name="terms" value="Accept">
  <input id="leadid_token" name="jornaya_leadid" type="hidden" value="8EDF9207-D7BD-45F4-3430-6D3EAA156E51">
  <div id="signaturehidden"></div>
  <div id="phidden"></div>
  <div id="dhidden"></div>
  <div id="sub1hidden"></div>
  <div id="sub2hidden"></div>
  <div id="trusthidden"></div>
  <div id="medihidden"></div>
  <div id="body" class="container-fluid body-01">
    <div class="row margin-none-01">
      <div class="col-12">
        <p class="text-04">Check Eligibility and Enroll Today</p>
        <div class="form-box-01">
          <!-- Permission -->
          <div id="perm" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">I give permission to Peace Tree Insurance, Christian Jerome, and their affiliates to access and/or create my application for health insurance on the Federally Facilitated Marketplace (FFM) based on the information I
                am providing below. <span class="required-01">*</span></p>
              <input type="radio" class="" id="give_permission" name="give_permission" value="yes"> <span class="text-06">Yes, I give Permision.</span>
            </div>
          </div>
          <!-- Medicare -->
          <div id="medi" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">Do you have insurance through your employer, Medicare, Medicaid or VA? <span class="required-01">*</span></p>
              <input type="radio" class="" id="medicareyes" name="medicare" value="yes"> Yes <input type="radio" class="" id="medicareno" name="medicare" value="no"> <span class="text-06">No</span>
            </div>
          </div>
          <!-- DOB -->
          <div id="dob" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">Main Applicant Date of Birth <span class="required-01">*</span></p>
              <input type="text" class="input-01" id="date_of_birth" name="date_of_birth" placeholder="Enter: MM-DD-YYYY" value="">
            </div>
          </div>
          <!-- Name -->
          <div id="name" class="row margin-none-01">
            <div class="col-12 col-md-6 col-lg-6">
              <p class="text-05">First Name <span class="required-01">*</span></p>
              <input type="text" class="input-01" id="first_name" name="first_name" placeholder="Enter First Name" value="">
            </div>
            <div class="col-12 col-md-6 col-lg-6">
              <p class="text-05">Last Name <span class="required-01">*</span></p>
              <input type="text" class="input-01" id="last_name" name="last_name" placeholder="Enter Last Name" value="">
            </div>
          </div>
          <!-- Phone / Email -->
          <div id="phem" class="row margin-none-01">
            <div class="col-12 col-md-6 col-lg-6">
              <p class="text-05">Phone <span class="required-01">*</span></p>
              <input type="text" class="input-01" id="phone" name="phone" placeholder="Enter Phone" value="">
            </div>
            <div class="col-12 col-md-6 col-lg-6">
              <p class="text-05">Email <span class="required-01">*</span></p>
              <input type="text" class="input-01" id="email" name="email" placeholder="Enter Email" value="">
            </div>
          </div>
          <!-- Address -->
          <div id="addy" class="row margin-none-01">
            <div class="col-12 col-md-6 col-lg-6">
              <p class="text-05">Address <span class="required-01">*</span></p>
              <input type="text" class="input-01" id="address" name="address" placeholder="Enter Address" value="">
            </div>
            <div class="col-12 col-md-6 col-lg-6">
              <p class="text-05">City <span class="required-01">*</span></p>
              <input type="text" class="input-01" id="city" name="city" placeholder="Enter city" value="">
            </div>
            <div class="col-12 col-md-6 col-lg-6">
              <p class="text-05">State <span class="required-01">*</span></p>
              <input type="text" class="input-01" id="state" name="state" placeholder="Enter State" value="">
            </div>
            <div class="col-12 col-md-6 col-lg-6">
              <p class="text-05">Zip Code <span class="required-01">*</span></p>
              <input type="text" class="input-01" id="zip_code" name="zip_code" placeholder="Enter Zip Code" value="">
            </div>
          </div>
          <!-- SSN / Gender / Married -->
          <div id="combo" class="row margin-none-01">
            <div class="col-12 col-sm-4 col-md-4 col-lg-4">
              <p class="text-05">Social Security Number <span class="required-01">*</span></p>
              <input type="text" class="input-01" id="ssn" name="ssn" placeholder="Social Security Number" value="">
            </div>
            <div class="col-12 col-sm-4 col-md-4 col-lg-4 mb-mobile-01">
              <p class="text-05">Gender <span class="required-01">*</span></p>
              <input type="radio" class="" id="genderyes" name="gender" value="male"> <span class="text-06">Male</span> <input type="radio" class="" id="genderno" name="gender" value="female"> <span class="text-06">Female</span>
            </div>
            <div class="col-12 col-sm-4 col-md-4 col-lg-4">
              <p class="text-05">Marital Status <span class="required-01">*</span></p>
              <input type="radio" class="" id="marriedyes" name="married" value="married"> <span class="text-06">Married</span> <input type="radio" class="" id="marriedno" name="married" value="single"> <span class="text-06">Single</span>
            </div>
            <div class="col-12">
              <div id="spodrop" class="spouse-box-01">
                <p class="">Spouse</p>
                <div class="row margin-none-01">
                  <div class="col-12 col-md-4 col-lg-4">
                    <p class="text-05">First Name <span class="required-01">*</span></p>
                    <input type="text" class="input-01" id="spouce_fname" name="spouce_fname" placeholder="First Name" value="">
                  </div>
                  <div class="col-12 col-md-4 col-lg-4">
                    <p class="text-05">Last Name <span class="required-01">*</span></p>
                    <input type="text" class="input-01" id="spouce_lname" name="spouce_lname" placeholder="Last Name" value="">
                  </div>
                  <div class="col-12 col-md-4 col-lg-4">
                    <p class="text-05">Gender <span class="required-01">*</span></p>
                    <input type="radio" class="" id="spogenderyes" name="spouce_gender" value="male"> <span class="text-06">Male</span> <input type="radio" class="" id="spogenderno" name="spouce_gender" value="Female"> <span
                      class="text-06">Female</span>
                  </div>
                  <div class="col-12 col-md-6 col-lg-6">
                    <p class="text-05">Spouse Date of Birth <span class="required-01">*</span></p>
                    <input type="text" class="input-01" id="spouce_birth" name="spouce_birth" placeholder="Enter: MM-DD-YYYY" value="">
                  </div>
                  <div class="col-12 col-md-6 col-lg-6">
                    <p class="text-05">Social Security Number</p>
                    <input type="text" class="input-01" id="spouce_ssn" name="spouce_ssn" placeholder="Social Security Number" value="">
                  </div>
                </div>
                <!--<p id="addspouse" class="btn-01">Add Spouse</p>-->
                <br>
              </div>
            </div>
          </div>
          <!-- Dependents -->
          <div id="dependent" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">Will you be claiming any dependents on your taxes in 2024? <span class="required-01">*</span></p>
              <input type="radio" class="" id="depyes" name="dependent" value="yes"> <span class="text-06">Yes</span> <input type="radio" class="" id="depno" name="dependent" value="no" checked=""> <span class="text-06">No</span>
              <div id="depdrop" class="dependent-box-01">
                <p class="">Dependent</p>
                <div class="row margin-none-01">
                  <div class="col-12 col-md-4 col-lg-4">
                    <p class="text-05">First Name <span class="required-01">*</span></p>
                    <input type="text" class="input-01" id="depone_fname" name="depone_fname" placeholder="First Name" value="">
                  </div>
                  <div class="col-12 col-md-4 col-lg-4">
                    <p class="text-05">Last Name <span class="required-01">*</span></p>
                    <input type="text" class="input-01" id="depone_lname" name="depone_lname" placeholder="Last Name" value="">
                  </div>
                  <div class="col-12 col-md-4 col-lg-4">
                    <p class="text-05">Gender <span class="required-01">*</span></p>
                    <input type="radio" class="" id="depgenderyes" name="depone_gender" value="male"> <span class="text-06">Male</span> <input type="radio" class="" id="depgenderno" name="depone_gender" value="female"> <span
                      class="text-06">Female</span>
                  </div>
                  <div class="col-12 col-md-6 col-lg-6">
                    <p class="text-05">Dependent Date of Birth <span class="required-01">*</span></p>
                    <input type="text" class="input-01" id="depone_birth" name="depone_birth" placeholder="Enter: MM-DD-YYYY" value="">
                  </div>
                  <div class="col-12 col-md-6 col-lg-6">
                    <p class="text-05">Social Security Number <span class="required-01">*</span></p>
                    <input type="text" class="input-01" id="depone_ssn" name="depone_ssn" placeholder="Social Security Number" value="">
                  </div>
                </div>
                <!--<p class="btn-01">Add Dependent</p>-->
                <br>
              </div>
            </div>
          </div>
          <!-- Income -->
          <div id="income" class="row margin-none-01">
            <div class="col-12 col-sm-8 col-md-8 col-lg-8">
              <p class="text-05">What is your estimated Household Income for 2024? <span class="required-01">*</span></p>
              <br>
              <div class="row">
                <div class="col-2">
                  <p id="rangemin" class="drag-text-01">$11,000</p>
                </div>
                <div class="col-8">
                </div>
                <div class="col-2">
                  <p id="rangemax" class="drag-text-02">$36,000</p>
                </div>
              </div>
              <div class="range">
                <input id="newdrag" name="range" type="range" min="11000" max="36000" value="" style="position: absolute; width: 1px; height: 1px; overflow: hidden; opacity: 0;">
                <div class="rangeslider rangeslider-horizontal" id="js-rangeslider-0">
                  <div class="rangeslider-fill-lower" style="width: 235px;"></div>
                  <div class="rangeslider-thumb" style="left: 232.5px;">
                    <div class="range-output">
                      <output id="showprice" class="output" name="output" for="range">$23,500</output>
                    </div>
                  </div>
                </div>
              </div>
              <img class="img-02" src="img/scales.png">
              <div class="row d-flex justify-content-center">
                <div class="col-5">
                  <p class="drag-text-04">$11,000</p>
                </div>
                <div class="col-5">
                  <p class="drag-text-05">$18,425</p>
                </div>
                <div class="col-5">
                  <p class="drag-text-05">$23,500</p>
                </div>
                <div class="col-5">
                  <p class="drag-text-05">$28,747</p>
                </div>
                <div class="col-5">
                  <p class="drag-text-06">$36,000</p>
                </div>
              </div>
            </div>
            <div class="col-12 col-sm-4 col-md-4 col-lg-4">
              <p class="text-05">Is that <span class="required-01">*</span></p>
              <input type="radio" class="" id="annual_income" name="annual_income" value="yes" checked=""> <span class="text-06">Yearly</span>
            </div>
          </div>
          <!-- Carriers -->
          <div id="carriers" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">Which $0 plan carriers are you interested in? <span class="required-01">*</span></p>
              <input type="radio" class="" id="best" name="carrier" value="Best Option (Recommended)" checked=""> <span class="best-option-01">Best Option (Recommended)</span>
              <br>
              <input type="radio" class="" id="ambetter" name="carrier" value="Ambetter"> Ambetter <br>
              <input type="radio" class="" id="aetna" name="carrier" value="Aetna"> Aetna <br>
              <input type="radio" class="" id="cigna" name="carrier" value="Cigna"> Cigna <br>
              <input type="radio" class="" id="molina" name="carrier" value="Molina"> Molina <br>
              <input type="radio" class="" id="uhc" name="carrier" value="UHC"> UHC <br>
              <input type="radio" class="" id="oscar" name="carrier" value="Oscar"> Oscar <br>
              <p class="text-07">* If your plan choice is not available, a licensed agent will choose the best available $0 option for you</p>
            </div>
          </div>
          <!-- Tobacco -->
          <div id="" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">Do you use Tobacco Products?</p>
              <input type="radio" class="" id="tobaccono" name="tobacco" value="no"> <span class="text-06">No</span>
              <input type="radio" class="" id="tobaccoyes" name="tobacco" value="yes"> <span class="text-06">Yes</span>
            </div>
          </div>
          <!-- Perscriptions -->
          <div id="" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">Are you on any perscriptions?</p>
              <textarea id="perscriptions" name="perscriptions" class="" rows="4" cols="50" placeholder="Medication..."></textarea>
            </div>
          </div>
          <!-- Doctor -->
          <div id="" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">What’s your doctors name?</p>
              <input type="text" id="doctor" name="doctor" class="input-01" placeholder="Doctor Here...">
            </div>
          </div>
          <!-- Income Verification -->
          <div id="incver" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">Income Verification</p>
              <textarea class="" name="" id="" rows="3"
                placeholder="By clicking the checkbox below, I hereby provide consent and authorization to Peace Tree Insurance 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 Peace Tree Insurance LLC and/or its affiliates to submit an income verification letter on my behalf if required by the marketplace."
                readonly="readonly"></textarea>
              <p class="text-08">Do you Agree with the Income Verification? <span class="required-01">*</span></p>
              <input type="radio" class="" id="incverify" name="income_verification" value="yes"> <span class="text-06">Yes, I Agree</span>
            </div>
          </div>
          <!-- Enrollment -->
          <div id="enroll" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">Consent to Enrollment; Verification of Information</p>
              <textarea class="" name="" id="" rows="5"
                placeholder="By clicking the checkbox below, I hereby provide consent and authorization To Peace Tree 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 Peace Tree Insurance, LLC and/or its affiliates 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 help@peacetreeinsurance.com or calling (877)885-2833."
                readonly="readonly"></textarea>
              <p class="text-08">Do you Agree with the Consent? <span class="required-01">*</span></p>
              <input type="radio" class="" id="enrollment" name="enrollment" value="yes"> <span class="text-06">Yes, I Agree</span>
            </div>
          </div>
          <!-- Tax -->
          <div id="tax" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">Authorization and Tax attestation</p>
              <textarea class="" name="" id="" rows="10"
                placeholder="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; (5) 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."
                readonly="readonly"></textarea>
              <p class="text-08">Do you Agree with Authorization and Tax attestation? <span class="required-01">*</span></p>
              <input type="radio" class="" id="authtax" name="tax" value="yes"> <span class="text-06">Yes, I Agree</span>
            </div>
          </div>
          <!-- Consent -->
          <div id="consent" class="row margin-none-01">
            <div class="col-12">
              <p class="text-05">Consent Acknowledgement</p>
              <textarea class="" name="" id="" rows="10"
                placeholder="By clicking “I Agree”, I am providing my electronic signature expressly authorizing Peace Tree Insurance, 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 Peace Tree Insurance, 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 help@peacetreeinsurance.com or calling (877)885-2833."
                readonly="readonly"></textarea>
              <p class="text-08">Do you Agree with Consent Acknowledgement? <span class="required-01">*</span></p>
              <input type="radio" class="" id="" name="acknowledgement" value="Yes"> <span class="text-06">Yes, I Agree</span>
            </div>
          </div>
          <!-- Signature -->
          <div id="sign" class="row margin-none-01">
            <div id="signatureTop" class="row">
              <div class="col-12">
                <center>
                  <!-- Copy Box -->
                  <div id="createImg" style="width: 300px;">
                    <div class="js-signature" style="display: none;"><canvas width="300" height="100"
                        style="box-sizing: border-box; width: 300px; height: 100px; border: 1px dashed rgb(170, 170, 170); background: rgb(255, 255, 255); cursor: crosshair;" id="jq-signature-canvas-1"></canvas><canvas width="300" height="100"
                        id="jq-signature-canvas-1" style="box-sizing: border-box; width: 300px; height: 100px; border: 1px dashed rgb(170, 170, 170); background: rgb(255, 255, 255); cursor: crosshair;"></canvas></div>
                    <div class="js-signature"><canvas width="300" height="100" id="jq-signature-canvas-2"
                        style="box-sizing: border-box; width: 300px; height: 100px; border: 1px dashed rgb(170, 170, 170); background: rgb(255, 255, 255); cursor: crosshair;"></canvas></div>
                  </div>
                  <!-- Clear Button -->
                  <p id="clearBtn" class="btn btn-primary" onclick="clearCanvas();">Clear Canvas</p>
                  <!-- Copy Button -->
                  <button id="copybtn" type="button" class="btn btn-primary top" style="display: none;">Create/Send Image</button>
                  <!-- Display Image -->
                  <div id="img" style="display:none;opacity: 0;">
                    <img src="" id="newimg" class="top">
                  </div>
                  <!-- Display URL -->
                  <p id="showurl" class=""></p>
                </center>
              </div>
            </div>
          </div>
          <!-- Submit -->
          <div id="submit" class="row margin-none-01">
            <div class="col-12">
              <p class="text-09">By signing, I grant permission to act on my behalf and that of my entire household in matters related to enrollment in a Qualified Health Plan via the Federally Facilitated Marketplace. This authorization also extends
                to any authorized representative or power of attorney acting on my behalf. The agents empowered by this agreement are Peace tree Insurance LLC and/or its affiliates. These agents are authorized to locate existing Marketplace
                applications, complete applications for eligibility in various plans and programs, provide necessary ongoing maintenance, and respond to inquiries about my application from the Marketplace. I understand and agree that my personally
                identifiable information will be accessed and used solely for the objectives specified in this document. I attest that all the details I provide for the purposes of eligibility and enrollment will be accurate to the best of my
                ability. I am under no obligation to disclose additional personal or health-related information beyond what is required for these applications. My consent remains effective until I choose to revoke it. For any modifications or to
                revoke this consent, I can email help@peacetreeinsurance.com or by calling (877)885-2833.</p>
              <button type="submit" class="btn-02" id="form-submit-button">Review Application</button>
            </div>
          </div>
        </div>
      </div>
    </div>
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</form>

Text Content

OPEN ENROLLMENT 2024

CHECK ELIGIBILITY NOW

*Available Monday-Friday 10AM-7PM EST*

$0 Health Insurance Plan + Premium Tax Credit

Check Eligibility and Enroll Today

I give permission to Peace Tree Insurance, Christian Jerome, and their
affiliates to access and/or create my application for health insurance on the
Federally Facilitated Marketplace (FFM) based on the information I am providing
below. *

Yes, I give Permision.

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

Yes No

Main Applicant Date of Birth *

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Zip Code *

Social Security Number *

Gender *

Male Female

Marital Status *

Married Single

Spouse

First Name *

Last Name *

Gender *

Male Female

Spouse Date of Birth *

Social Security Number


Will you be claiming any dependents on your taxes in 2024? *

Yes No

Dependent

First Name *

Last Name *

Gender *

Male Female

Dependent Date of Birth *

Social Security Number *


What is your estimated Household Income for 2024? *


$11,000



$36,000

$23,500

$11,000

$18,425

$23,500

$28,747

$36,000

Is that *

Yearly

Which $0 plan carriers are you interested in? *

Best Option (Recommended)
Ambetter
Aetna
Cigna
Molina
UHC
Oscar


* If your plan choice is not available, a licensed agent will choose the best
available $0 option for you

Do you use Tobacco Products?

No Yes

Are you on any perscriptions?

What’s your doctors name?

Income Verification

Do you Agree with the Income Verification? *

Yes, I Agree

Consent to Enrollment; Verification of Information

Do you Agree with the Consent? *

Yes, I Agree

Authorization and Tax attestation

Do you Agree with Authorization and Tax attestation? *

Yes, I Agree

Consent Acknowledgement

Do you Agree with Consent Acknowledgement? *

Yes, I Agree

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By signing, I grant permission to act on my behalf and that of my entire
household in matters related to enrollment in a Qualified Health Plan via the
Federally Facilitated Marketplace. This authorization also extends to any
authorized representative or power of attorney acting on my behalf. The agents
empowered by this agreement are Peace tree Insurance LLC and/or its affiliates.
These agents are authorized to locate existing Marketplace applications,
complete applications for eligibility in various plans and programs, provide
necessary ongoing maintenance, and respond to inquiries about my application
from the Marketplace. I understand and agree that my personally identifiable
information will be accessed and used solely for the objectives specified in
this document. I attest that all the details I provide for the purposes of
eligibility and enrollment will be accurate to the best of my ability. I am
under no obligation to disclose additional personal or health-related
information beyond what is required for these applications. My consent remains
effective until I choose to revoke it. For any modifications or to revoke this
consent, I can email help@peacetreeinsurance.com or by calling (877)885-2833.

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