MarketPlace Exchange

The following information is required to evaluate your options via healthcare.gov. The system operates with the “no wrong door” goal. Regardless if you are eligible for Medicaid, premium subsidy, or cost sharing benefits, the system will provide the eligibility evaluation once your identity has been verified.

Please complete the following online form below or download & print this Marketplace PDF Worksheet / Questionnaire PDF and submit to Robyn Waller (robyn@financiallifecycles.com) prior to your scheduled appointment with Financial Life Cycles.

  • Dependents to be Insured ONLY




  • Digital Signature

  • Initial Here
  • Initial Here
  • I understand the above information will be used to confirm the identity of myself and eligible family members. I am providing my permission to Robyn Waller, Financial Life Cycles, to use the above information to review and enrollment in medical insurance. The above information will be verified by several state and federal agencies including but not limited to: Department of Labor, Health and Human Services, IRS, Social Security Administration, and the Credit Bureau. If this information changes during the plan year, my eligibility may change as well. I understand I am responsible to report these changes within 31 days as it may affect my benefits. Any changes not reported can result in tax penalties. I do not hold Financial Life Cycles responsible for incorrect calculations completed by healthcare.gov.