Consent Form

This Form Serves Two Purposes:

  1. Fulfills a government-required client consent, giving the agent/broker permission to work on your behalf as the "agent/broker of record" as it pertains to the quoting, application, and enrollment processes..
  2. Provides important and required disclosures for some plans.

This form is not your application for any insurance products, but is required for your agent/broker to be able to enroll you into certain plans.  If you have any questions, please ask your agent/broker.

Privacy Policy

Important Marketplace Emails: If the Marketplace has your email address, they’ll automatically send you important information, updates, and reminders about Marketplace enrollment. You can opt out of these communications at any time. To do this, click on the "unsubscribe" link in the footer of any Marketplace email.

Privacy and the use of your information: The Marketplace will keep your information private as required by law. Your answers on this form will only be used to determine eligibility for health coverage or help paying for coverage. The Marketplace will check your answers using the information in their databases and the databases of other federal agencies. If the information doesn't match, the Marketplace may ask you to send them proof. The Marketplace won't ask any questions about your medical history. Household members who don't want coverage won't be asked questions about citizenship or immigration status.

As part of the application process, the Marketplace may need to retrieve your information from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security (DHS), and/or a consumer reporting agency. They need this information to check your eligibility for coverage and help paying for coverage if you want it and to give you the best service possible.The Marketplace may also check your information at a later time to make sure your information is up to date. The Marketplace will notify you if they find something has changed.

Learn more about your data, or view the Privacy Act Statement.

By continuing, you (the consumer) grant your agent, and any government approved partner, permission to access your Marketplace application.

General Attestations

Tax-Related Attestations

If you are recieving a lower price based on income...

Savings eligibility is based on your household's modified adjusted gross income (MAGI). For most people, your household consists of the tax filer, spouse, and tax dependents, including those who don't need coverage.  Click here to review official government rules.

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 2023 tax year.
  • If I’m married at the end of 2023, 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 2023 federal income tax return.
  • I’ll claim a personal exemption deduction on my 2023 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.

Agent/Broker Information

If the agent information is not pre-filled below, please contact your agent.

Your Information