I have read and agree to the following Legal Disclosures: *
I attest that my estimated income for 2023 will be at least the Federal Poverty Limit for my state and household size. I agree to notify We Solve Insurance, LLC as soon as I become aware of any changes to the expected household income per month that I have provided above. I understand that failure to notify We Solve Insurance, LLC of such changes may affect my eligibility.
In some cases, it may be necessary to verify your income. If income verification is required by the Marketplace, I authorize We Solve Insurance, LLC to submit an income attestation letter on my behalf with the information that I have provided.
By signing below, I hereby provide consent and authorize We Solve Insurance, LLC to enroll me and any other individuals I identified above in an ACA Plan available through the Federally Facilitated Exchange (the “Marketplace”). If I already have health insurance, I request that We Solve Insurance, LLC and its agents become my agent of record or switch me to a better plan if one is available. This consent will remain in effect unless and until rescinded by you in writing. This consent can be rescinded at any time by sending an email to firstname.lastname@example.org.
Additionally, by signing below I attest to the fact that I have reviewed the information I have provided above and that it is accurate and complete in all material respects.
Use of Personal Information
My consent for We Solve Insurance, LLC to disclose my personal information will remain in effect until I revoke or modify my consent. I may revoke or modify my consent at any time and/or obtain a copy of this form by sending an email to email@example.com. However, please note that if you revoke your consent, we will not be able to further disclose your personal information and offer our services. We Solve Insurance, LLC will maintain this form or a true and correct copy of this form in its records. You may want to make a copy of this form for your records.
I understand that I’m required to provide true and complete answers to the questions posed above and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If the information provided by me is not true and complete I may face penalties, including the risk of losing my eligibility for coverage.
I understand that if anyone I identified above as needing coverage is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage.
Renewal of 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 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.
I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicare, 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 don’t, the person who files taxes in my household may need to pay back my premium tax credit.
I understand the foregoing does not constitute tax advice provided by We Solve Insurance, LLC to me, and that should I have any questions regarding any tax credits for which I may be eligible, my tax returns, or any other related tax matters I should consult a qualified tax advisor prior to enrolling in health insurance coverage provided via the Marketplace.
Electronic Signature and Communications
I consent to receive all notices electronically and to the use of an electronic signature to sign all forms presented to me by We Solve Insurance, LLC during the health insurance enrollment process, including, without limitation, privacy policies, consent forms, and to sign this form below, unless and until I withdraw my consent to the use of electronic signatures by providing notice to [insert contact info], in which case we will provide paper copies. I agree that this consent is effective on the date that I affix my signature below.
Limited Power of Attorney
I also grant We Solve Insurance, LLC and/or its designees and agents a limited power of attorney to enroll me in a Marketplace health insurance plan and to automatically enroll me in a plan at renewal. Void where prohibited.
By signing below, I agree to be legally bound as if I had signed this form and other documents with a handwritten signature, and I acknowledge that I have reviewed and agree to the above terms and conditions.
By signing below, I am confirming that I am the owner or primary user of the mobile phone number provided or am authorized to provide the consent of the owner or primary user to receive calls or messages at that mobile phone number. I, or the individual on whose behalf I am acting, agree to receive marketing calls or text messages at the phone number provided, including autodialed or prerecorded message calls or text messages. Consent is not a condition of any purchase. Message and data rates may apply.
I understand that at this time I have not yet applied for health insurance, and that We Solve Insurance, LLC. will be using the information and consents I provide herein to fill out, sign, and submit the Marketplace application on my behalf, and take any other actions pursuant to the authority I delegated to We Solve Insurance, LLC which are deemed necessary or appropriate by We Solve Insurance, LLC to obtain coverage on my behalf.
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.