* If NOT a US Citizen, do you have a Green Card? COPY OF CARD IS REQUIRED
If employed, please provide the following information:
MARKETPLACE CONSENT AND AUTHORIZATION
, give my permission to The Insurance Hub LLC (hereafter TIH) to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace.
By consenting to this agreement, I authorize TIH to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:
Searching for an existing Marketplace application;
- Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP, or advance tax credits to help pay for Marketplace premiums;
Obtaining and submitting my personal information including my photograph, voice, copy of Driver’s License, Green Card, Visa, Naturalization Documents, Social Security Card, Birth Certificate, and/or Income verification for the sole purpose of verifying my identity and citizenship;
- Providing ongoing account maintenance and enrollment assistance as necessary;
- Responding to inquiries from the Marketplace regarding my Marketplace application;
- Accessing my family’s Marketplace, healthcare.gov, Medicare, and Medicaid accounts for the purpose of enrolling me in a free or next best available health plan;
- Switching me to a better plan if one is available, and if I am already on the best plan, TIH may become my agent of record from this point forward.
If I am currently covered by Medicare, Medicaid, Disability, receiving Unemployment Benefits, or enrolled in any marketplace plan, I understand:
- Enrolling for health insurance through the Marketplace may affect my current benefits.
- I am not eligible for a premium tax credit if I am found eligible for other qualifying health coverage, such as Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan.
- 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 fail to do so, the person who files taxes in my household may need to pay back my premium tax credit.
- Since 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 every tax year I am receiving health insurance through the Marketplace. Therefore, I agree to file a federal income tax return for every year I am on Marketplace insurance.
- If I am married at the end of each year and I am on Marketplace insurance, I must file a joint income tax return with my spouse.
- No one else will be able to claim me, nor any of my dependents on their 2023 federal tax return.
- If any of the above information changes, it may impact my ability to get the premium tax credit. I also understand that when I file my federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application, and 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 tax income.
- By signing this form, I grant TIH a limited power of attorney to help me get enrolled in a Marketplace health insurance plan or another affordable healthcare plan. I also request that TIH use this limited power of attorney to automatically assist me in a plan for renewal on an annual basis.
- By signing this form, whether electronically or in person, TIH may contact me at the number, address, and email address provided with this application or to obtain additional information for such purpose, via live, prerecorded, or auto-dialed calls, text messages, and emails for a period of 5 years.
- I grant permission to resubmit and copy and paste my signature on my behalf into the agent’s electronic portal/website to assist me in applying for healthcare insurance.
- It is my responsibility to provide proof of income, citizenship, non-incarceration, and any additional information as may be required by government entities.
I acknowledge that I am signing this application under the penalty of perjury, and therefore, affirm that all answers provided to the best of my knowledge are true and accurate. I also acknowledge that providing false information intentionally may subject me to loss of health insurance and penalties under federal law. I understand that TIH will not use or share my personally identifiable information (PII) for any purposes other than those listed above. TIH will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.
I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by written notice, and such revocation will take effect the first day of the month following receipt by TIH.
Name of Agency: The Insurance Hub LLC Agency
Owner of Agency: Cesar Chacon
Phone Number: 941-706-1111
National Producer Number: 16680739
Email Address: firstname.lastname@example.org
Address: 5969 Cattlemen Lane, Sarasota, FL 3423