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info@yisbenefits.com

Drop us a line

866-726-4966

Make a call

The YIS 5 minute Health Insurance Application

We have helped families with their Marketplace application since 2014. We have created this form to assist you through the enrollment process. We will never call you. Only a text or email if there is an issue with your new health insurance. 
You can call us at any time at
866-726-4966.

SIGN UP ONLINE

You are one step from new coverage. We work with every carrier in the state and will place you in the best option in your situation. Our goal is to place you in a $0 PREMIUM plan.
How many people need coverage?
  • - select a option -
  • 1
  • 2
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  • 10
Field is required!

SIGN UP ONLINE

You are one step from new coverage. We work with every carrier in the state and will place you in the best option in your situation. Our goal is to place you in a $0 PREMIUM plan.
Are you married?
Field is required!

SIGN UP ONLINE

You are one step from new coverage. We work with every carrier in the state and will place you in the best option in your situation. Our goal is to place you in a $0 PREMIUM plan.
Do you want to apply for a subsidy to pay for your insurance?
Field is required!

SIGN UP ONLINE

You are one step from new coverage. We work with every carrier in the state and will place you in the best option in your situation. Our goal is to place you in a $0 PREMIUM plan.
Field is required!
Field is required!
Need coverage
Field is required!
Field is required!
Invalid phonenumber!
Address
Field is required!
Field is required!
Field is required!
  • - select your country -
  • Åland Islands
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa (US)
  • Andorra
  • Angola
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda (UK)
  • Bhutan
  • Bolivia
  • Bosnia and Herzegovina
  • Botswana
  • Brazil
  • Brunei
  • Bulgaria
  • Burkina Faso
  • Burma (Myanmar)
  • Burundi
  • Cambodia
  • Cameroon
  • Canada
  • Cape Verde
  • Central African Republic
  • Chad
  • Chile
  • China
  • Colombia
  • Comoros
  • Congo, Democratic Republic of the
  • Congo, Republic of the
  • Cook Islands (NZ)
  • Costa Rica
  • Croatia
  • Cuba
  • Cyprus
  • Czech Republic
  • Denmark
  • Djibouti
  • Dominica
  • Dominican Republic
  • East Timor (Timor-Leste)
  • Ecuador
  • Egypt
  • El Salvador
  • Equatorial Guinea
  • Eritrea
  • Estonia
  • Ethiopia
  • Falkland Islands (UK)
  • Faroe Islands (Denmark)
  • Fiji
  • Finland
  • France
  • French Guiana
  • French Polynesia (France)
  • Gabon
  • Gambia
  • Georgia
  • Germany
  • Ghana
  • Gibraltar (UK)
  • Greece
  • Greenland (Denmark)
  • Grenada
  • Guam (US)
  • Guatemala
  • Guernsey (UK)
  • Guinea
  • Guinea-Bissau
  • Guyana
  • Haiti
  • Honduras
  • Hong Kong (China)
  • Hungary
  • Iceland
  • India
  • Indonesia
  • Iran
  • Iraq
  • Ireland
  • Isle of Man (UK)
  • Israel
  • Italy
  • Ivory Coast
  • Jamaica
  • Japan
  • Jersey (UK)
  • Jordan
  • Kazakhstan
  • Kenya
  • Kiribati
  • Korea, North
  • Korea, South
  • Kosovo
  • Kuwait
  • Kyrgyzstan
  • Laos
  • Latvia
  • Lebanon
  • Lesotho
  • Liberia
  • Libya
  • Liechtenstein
  • Lithuania
  • Luxembourg
  • Macau (China)
  • Macedonia
  • Madagascar
  • Malawi
  • Malaysia
  • Maldives
  • Mali
  • Malta
  • Marshall Islands
  • Mauritania
  • Mauritius
  • Mayotte (France)
  • Mexico
  • Micronesia, Federated States of
  • Moldova
  • Monaco
  • Mongolia
  • Montenegro
  • Morocco
  • Mozambique
  • Namibia
  • Nauru
  • Nepal
  • Netherlands
  • New Caledonia (France)
  • New Zealand
  • Nicaragua
  • Niger
  • Nigeria
  • Niue (NZ)
  • Norfolk Island (Australia)
  • Northern Mariana Islands (US)
  • Norway
  • Oman
  • Pakistan
  • Palau
  • Palestinian territories
  • Panama
  • Papua New Guinea
  • Paraguay
  • Peru
  • Philippines
  • Pitcairn Islands (UK)
  • Poland
  • Portugal
  • Qatar
  • Réunion (France)
  • Romania
  • Russian Federation
  • Rwanda
  • São Tomé and Príncipe
  • Saint Helena, Ascension and Tristan da Cunha (UK)
  • Saint Kitts and Nevis
  • Saint Lucia
  • Saint Pierre and Miquelon (France)
  • Saint Vincent and the Grenadines
  • Samoa
  • San Marino
  • Saudi Arabia
  • Senegal
  • Serbia
  • Seychelles
  • Sierra Leone
  • Singapore
  • Slovakia
  • Slovenia
  • Solomon Islands
  • Somalia
  • South Africa
  • South Sudan
  • Spain
  • Sri Lanka
  • Sudan
  • Suriname
  • Svalbard and Jan Mayen (Norway)
  • Swaziland
  • Sweden
  • Switzerland
  • Syria
  • Taiwan
  • Tajikistan
  • Tanzania
  • Thailand
  • Togo
  • Tokelau (NZ)
  • Tonga
  • Trinidad and Tobago
  • Tunisia
  • Turkey
  • Turkmenistan
  • Tuvalu
  • Uganda
  • Ukraine
  • United Arab Emirates
  • United Kingdom
  • United States
  • Uruguay
  • Uzbekistan
  • Vanuatu
  • Vatican City
  • Venezuela
  • Vietnam
  • Wallis and Futuna (France)
  • Western Sahara
  • Yemen
  • Zambia
  • Zimbabwe
Field is required!
Field is required!
Social Security Number
Socials are NOT REQUIRED to get insurance started. BUT you will need to provide within 90 days
Field is required!
Name of Employer
Type Self if Self employed
Field is required!
Expected income per month?
Field is required!
Spouse Name
Field is required!
Need coverage?
Field is required!
Field is required!
Social Security Number
Socials are NOT REQUIRED to get insurance started. BUT you will need to provide within 90 days
Field is required!
Name of Employer
Type Self if Self employed
Field is required!
Expected income per month?
Field is required!
Do you claim any dependents?
  • - Select -
  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
Field is required!
Name
Field is required!
Need coverage
Field is required!
Field is required!
Field is required!
Social Security Number
Socials are NOT REQUIRED to get insurance started. BUT you will need to provide within 90 days
Field is required!
Do you authorize YIS Benefits to place you in an insurance plan?
Field is required!
Do you give YIS Benefits authorization to access your Marketplace Account and make changes if needed?
Field is required!
Do you have insurance through your employer, Medicare or VA?
Field is required!
I attest from this day forward Michael Schellbach will be the agent of record for my health insurance plan With the marketplace and will only be replaced by another agent if written notice is submitted to him.
Field is required!

This form is to be used to help you insure you and your family. The information provided must be accurate for the subsidies to be accurate. Our job is impossible with incorrect information. Submitting this form tells us that to the best of your knowledge all of the above information is accurate. You will not receive any phone calls from YIS Benefits. We will however text or email you if the Marketplace requests anything from you. You will also receive everything in the mail. Let us know if you need any further assistance.