Field Team Application Authorization

  • Legal FIRST and LAST Name as it appears on your Social Security Card

  • MM slash DD slash YYYY
  • Contact Information

  • Tax Information

  • List Their Names Below:
  • Dependent 1

  • MM slash DD slash YYYY
  • Dependent 2

  • MM slash DD slash YYYY
  • Dependent 3

  • MM slash DD slash YYYY
  • Income

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      I hereby grant permission to The Insurance Hub ("TIH"), its affiliates, and selected agents to access my family’s marketplace,, Medicare, and Medicaid accounts for the purpose of enrolling me in a free or next best available health plan. By signing this application, I acknowledge that I understand that TIH may switch me to a better plan if one is available and that if I am already on the best plan, TIH may become my agent of record from this point forward, unless I notify TIH in writing of the change.

      I understand that my information will be used and retrieved from government data sources for this application, and I have obtained consent from all people listed on this application for their information to be retrieved and used from government data sources. I acknowledge that it is my responsibility to provide true and accurate answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. I understand that failure to provide true and accurate information may result in penalties, including the risk of losing my eligibility for 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 five years. The Marketplace will send me a notice and allow me to make any changes, and I can opt-out at any time.

      If I am currently covered by Medicare, Medicaid, Disability or receiving Unemployment Benefits, I understand that enrolling for health insurance through the Marketplace may affect my current benefits.

      I understand that 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. I acknowledge 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 fail to do so, the person who files taxes in my household may need to pay back my premium tax credit. I also 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 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, I am on Marketplace insurance; 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 tax return for an individual listed on my application as my dependent who is enrolled in coverage through the Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.

      I acknowledge that 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.

      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. If requires income verification or any other documents on Marketplace application, I grant TIH permission to submit those documents and an income verification estimation.

      I hereby grant my consent to TIH to collect my personal information, including but not limited to my ID, Social Security Card, Birth Certificate, Passport, Immigration form, and any other personal documents that may be necessary to facilitate my enrollment in healthcare insurance through the Marketplace.

      Furthermore, I authorize TIH to obtain and utilize my personal information, including my photograph, voice, copy of Driver’s License, Green Card, Visa, Naturalization Documents, Social Security Card, Birth Certificate, for the sole purpose of verifying my identity and citizenship.

      By affixing my electronic signature to this application, I acknowledge and agree that I am expressly authorizing TIH to 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, emails, for a period of 5 years.

      I further agree that upon the execution of my electronic application through TIH, 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.

      Moreover, I understand that 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 penalties under federal law.

    • By signing above, you agree that all the information provided by you in this application is true and accurate.