Intro Disclaimer:

Our licensed agents and trained staff are authorized to collect Personally Identifiable Information (PII).  We may share this information with CMS (the Obamacare Headquarters) to enroll you for health insurance.  This request for (PII) is voluntary.  If you choose not to provide us with the (PII) requested, this could affect or delay your ability to enroll in a health insurance policy.

Policy Details:

A licensed health insurance agent will enroll you in a health insurance plan that will cost you $0/month. The plan will also include co-payments to provide affordable access to your primary care physician.  All plans will include an annual physical at no cost to you.  If a $0 plan is not available, your agent will enroll you in the lowest cost plan.  To discuss the details or make changes to the plan we will assign you, please contact us at 833-MY-OBAMA (696-2262).

Closing Disclaimer:

You agree all the information you provided is true and accurate. You also acknowledge your $0 monthly payment is based on receiving an Advanced Premium Tax Credit which is also called a ‘Subsidy.’

You give a licensed agent permission to enroll you in a health insurance plan.  You also give your consent and allow a licensed agent to re-enroll you in a health plan with a similar monthly premium following the expiration of the initial plan that was issued.  This plan may be with the same carrier we originally enrolled you with or a different carrier.  You give your licensed agent, or another trained individual from our team permission to send you text message notifications and update your personal and financial information in the marketplace.  You also agree to call your licensed agent or the marketplace if any of your personal or financial information you provided us changes or you need to make changes to your policy.  This authorization will remain enforced for 24 months from the date this document is signed.

I understand that I am 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 do not, I may face penalties, including the risk of losing my eligibility for coverage.  I agree to have my information used and retrieved from data sources for this application.  I have consent for all people I will list on the application for their information to be retrieved and used from data sources.  You don’t have to file taxes to apply for coverage, but you’ll need to file next year if you want to get a premium tax credit to help pay for coverage now.  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 opt out at any time.  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.