Check Your Eligibility

Wondering if you qualify? Fill out the form below to find out instantly

1
Your Information
2
Business Information
3
Agent Information
4
Review & Submit
Step 1:

General Information

Please enter your first name.
Please enter your last name.
Please enter a valid email.
Please enter your company.
Please enter your job title .
Please select your industry.
Please enter website option.
Please enter your adress.
Please enter your phone number .
Please select your state
Please select your city
Please enter your zip code .
Step 2:

Business Information

Please select an option.
Please select an option.
Please enter your total number of w2 employees .
Please enter Number of total W2 employees
please enter your annual Earning of full-tisme W2 employees
Please enter your of total part-Time W2 employees
Please enter average earning of total W2 employees
Step 3:

Agent Information

Please enter your Agent name .
please enter your company name
Please enter a valid email.

Step 4:

Review & Submit

1. Your Information

Edit Information

First Name *

Last Name *

Email *

Company *

Job Title *

Industry *

Website (Optional)

Address *

Phone Number *

City *

State *

Zip *

2. Business Information

Edit Information

Do you offer Group Health Insurance? *

Do you have 10 or more W2 Full-Time Employees? *

Number of total Full-Time W2 employees? *

56 Employees

Number of total W2 employees? *

10 Employees

Average Annual Earnings of Full-time W2 employees? *

$ 200

Number of total part-time W2 employees? *

12 Employees

Average Earnings of Part-time W2 employees? *

$ 100

3. Agent Information

Edit Information

Agent Name *

Virginia Fish

Company Name *

ACA Solutions HUB

Email *

virginiafish@mbeshawlands.co.uk

Co-Agent (Optional)

Ryan

Affiliate (Optional)

BrightTech Solutions

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