Consent Form

This Form Serves Two Purposes:

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..
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.

I agree to have my information used and retrieved from data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from data sources. *

Yes, I Agree

I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage. *

Yes, I Agree

General Attestations

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. *

Yes, I Agree

I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). I know a change in my information could affect eligibility for member(s) of my household. *

Yes, I Agree

If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or Children's Health Insurance Program (CHIP)), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost. *

Yes, I Agree to allow the Marketplace to end the Marketplace coverage of the people on my application in this situation

I understand that I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information. *

Yes, I Agree

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 I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, 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 don’t, the person who files taxes in my household may need to pay back my premium tax credit.

Yes, I Understand

Yes, I Understand

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.

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 2023 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.

Yes, I Understand

Agent/Broker Information

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

Agent/Broker Name *

Agent Email *

Agent NPN *

I give permission for the above listed agent to work on my behalf as it relates to the quoting, application, enrollment, and servicing of my health insurance plan(s)

Yes, I Agree

Your Information

Primary Applicant *

First

Last

Spouse/Secondary Applicant

First

Last

Preferred Email Address *

Signature

Signature (use mouse/finger)

Type In Your Name *

Single Line Text

Single Line Text *

This Form Serves Two Purposes:

Privacy Policy

General Attestations

Tax-Related Attestations

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

Agent/Broker Information

Your Information

Signature

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Legal

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