Welcome to Badger Health Insurance LLC!! My name is Tracy Badger and I am a licensed Life and Health Insurance Agent in GA, FL, AL, SC, and TX. My agency specializes in getting people the right insurance for them without all of the misleading marketing and just focus on doing the right thing at all times, integrity. Filling out this application will send all of your information directly to me in my HIPPA compliant system and I will complete your application and send you the details of your plan within 28-48 hours. If you get stuck on any question, please send me a text at (470) 493-5989 and I will be happy to help. If we need to jump on a call, we can do that too but texting is the quickest way to reach me. Also save 678-680-5811, that's the number that my automated system uses to send out messages too.

*READ: When filling out this application, think about what's going to happen between Jan-Dec 2024. I know it's hard to predict the future but when you are thinking about your income and dependents, the questions are asking what/how you will file your taxes for the following year. Household size only means those people that you will claim on you taxes next year. If you have a roommate or adult children that you will not claim on your taxes, do not add them to the application. If they are seeking coverage too, have them fill out a form for themselves and I'll take care of them too.*

APPLICANT INFORMATION

Full Name *

Phone *

Address *

City *

State *

Postal code *

County *

Date of birth *

Social Security Number *

Are you a US citizen? If not, please provide citizenship number *

Sex *

Male

Female

Tobacco User?

Expected Income for 2024 *

In order to be eligible for Marketplace coverage, you will need to predict that you can make at least the minimum income based on your family size. See the chart below to determine If projected income meets the minimum requirement to receive a subsidy from the Marketplace.

Name of Your Employer

If you are currently unemployed but expect that you will get a job or at least meet the minimum income requirements for next year, put that you are self employed and we can update it later when you actually start working.

Employer Phone Number

If your employer offers insurance, how much is it per month?

READ: If you are married, you must file joint taxes even if your spouse isn't applying for coverage

SPOUSE INFORMATION

Does Spouse Need Coverage?

Yes

Spouse Name

Spouse Date of Birth

Spouse Social Security Number

Name of Employer for Spouse

Spouse Expected Income Per Month

Spouse a Tobacco User?

Sex of Spouse

DEPENDENT INFORMATION

READ: If you have any dependents that you will claim on your taxes when you file them in January of 2025, please add them to the application even if they are not getting coverage. If the are not getting coverege, I will only need their name, date of birth and sex. If they are getting Marketplace coverege, add their Social Security Number to the application.

Dependent #1

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Dependent #2

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

Dependent #3

Full Name
Relationship to Applicant
Birthday
Social Security Number
Do They Need Coverage?

If you have any more dependents, add their information here.

If you or your dependents on this application see any doctors, put their name and the city that they're in here so that I can look them up.

If you or your dependents take any prescriptions that you need to make sure are covered, put the name of the prescription, the amount you take every month, and the dosage here.

FINAL AGREEMENTS

Read all of the required agreement!!

Agreements

Please read the attestations below.

Renewal of eligibility

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.

Tax attestation

Please read the attestations below.

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.

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 2024 tax year.
If l'm married at the end of 2024, 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 2024 federal income tax return.
I'll claim a personal exemption deduction on my 2024 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 2024 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.

Sign and submit

Please read the attestations below.

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.

If anyone on your application is enrolled in Marketplace coverage and is also found to have Medicare coverage, the Marketplace will automatically end their Marketplace plan coverage. They will get a notice before Marketplace terminates their coverage in case they need to keep it or make changes. During all the months of overlapping coverage, they're responsible for paying the full cost for the Marketplace plan premium and covered services.

I agree to allow the Marketplace to end the Marketplace coverage for anyone on my application who's enrolled in both Marketplace and Medicare coverage.

Sign

I'm signing this application under penalty of perjury, which means l'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.

I have read and agree to the terms above *

YES

Signature

Clear