Terms and Conditions

In some cases, it may be necessary to verify your income. If income verification is required in order to complete your enrollment, do you authorize your listed Broker, who will be your Agent Of Record to submit an income attestation letter on your behalf with the information that you have provided?

If we change your plan, you understand that your deductible and/or annual maximum out of pocket will start over again once your new policy begins. If you are not currently covered (you stated you did not have coverage currently at the beginning of the application), this will not apply/affect you.

If your income is $0 (or less than the Federal Poverty Limit), you attest that your estimated income for 2025 will be at least the Federal Poverty Limit for your state and household requirements. If your income will be less than (or greater than) those limits, you agree to notify us or the Marketplace of any changes or updates as soon as possible. Failure to notify us of any changes may result in your eligibility being affected. I agree to notify my Broker  if my estimated income for 2025 changes.

Please read the attestations below and sign if you agree. Use of Personal Information:

I consent to the use and disclosure by my noted Broker of (a) the personal information I have provided about myself and others in the questionnaire above, and (b) any other personal information about myself or the other individuals listed above which may be obtained by my Broker from government data sources, for purposes of applying for health insurance coverage through the Federally Facilitated Exchange (the “Marketplace”).

I agree to these websites Privacy Policy and Terms of Use. If you have questions about our Privacy Policy, please Contact Us. Each request is subject to verification. California and Nevada residents exercising the right to opt out of the sale of their data should access our Do Not Sell My Info form here. For more information regarding these privacy matters, please refer to our Privacy Policy.

Eligibility:

I understand that I am required to provide true and complete answers to the questions posed above and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If the information provided by me is not true and complete I may face penalties, including the risk of losing my eligibility for coverage. I know a change in my information could affect eligibility for member(s) of my household. I understand that if anyone I identified above as needing coverage is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who is found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.

Renewal of Coverage:

To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.

Tax Attestation:

If I received premium tax credits in 2022, 2023, and 2024 I attest that I filed a tax return with form 8962 for at least one of those years. I understand that I am not eligible for a premium tax credit if I am found eligible for other qualifying health coverage, like Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I do not, the person who files taxes in my household may need to pay back my premium tax credit. I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: I must file a federal income tax return for the 2025 tax year.

If I’m married at the end of 2025, I must file a joint income tax return with my spouse. I also expect that: No one else will be able to claim me as a dependent on their 2025 federal income tax return. I’ll claim a personal exemption deduction on my 2025 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.

IF ANY OF THE ABOVE CHANGES: I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2025 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

Electronic Signatures and Communications:

I consent to the use of an electronic signature to sign all forms presented to me during the health insurance enrollment process, including, without limitation, to signing this form below, unless and until I withdraw my consent to the use of electronic signatures by providing notice.  I agree that this consent is effective on the date that I affix my signature below and by supplying my initials above. By signing below, I agree to be legally bound as if I had signed this form and other documents with a handwritten signature, and I acknowledge that I have reviewed and I agree to the above terms and conditions.

I understand that at this time I have not yet applied for Federally Facilitated Exchange health insurance, and my Broker will be using the information and consents I provide herein to fill out, sign on my behalf, and submit the Federally Facilitated Exchange application. This form is used to help to find insurance for you and your family.

The information provided must be accurate for the subsidies to be accurate. Failure to provide the correct information could result in claims being invalidated or the termination of your insurance policy. By submitting an application, you confirm that the information is accurate to the best of your knowledge.

Consent to Enrollment

By supplying my initials and signing below, I hereby provide consent and authorization to my Broker, also known as my Agent of Record to enroll me and/or my family in a health insurance plan through the ACA Marketplace at no cost to me. I grant permission for  my Broker to access my healthcare.gov account for the purpose of quoting, enrolling, and maintaining my health insurance. I agree to additional consent located here https://www.cms.gov/files/document/cms-model-consent-form-marketplace-agents-and-brokers.pdf and approve my digital signature be place on all consent forms with my listed Health Insurance Agent of  Record.