Are you currently employed *

Yes

Name of Your Employer

Do you have insurance through your employer, Medicare or VA? *

Yes, from my employer

Yes, from medicare

Yes, from the VA

First Name *

Last Name *

Gender *

Male

Female

Street Address *

City *

State *

Postal code *

Country *

Phone *

Email *

Your Enrollment confirmation will be sent here

Main Applicant's birth date(D.O.B) *

This must be accurate to enroll in a marketplace plan

Main applicant social security number *

This must be accurate to enroll in a marketplace plan

Main Applicant Expected Income *

Are you married *

Yes

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

Do you wish to apply for a subsidy to pay for your insurance? *

Yes

Do you currently have healthcare.gov Access? *

Yes

Do You Claim Any Dependents? *

Yes

How many people need coverage? *

If your income is $0 (or less than the Federal Poverty Limit), you attest that your estimated income for 2023 will be at least the Federal Poverty Limit for your state and household requirements. If your income is less than (or greater than) those limits, you agree to notify us or the marketplace of any changes or updates as soon as possible. Failure to notify us of any changes may result in your eligibility being affected. Job Seeking: I agree to notify Patrick Caldwell (Agent) 10175770 if my estimated income for 2023 changes.

In some *

In some cases, it may be necessary to verify your income. If income verification is required to complete your enrollment, you authorize Patrick Caldwell (Agent) 10175770 to submit an income attestation letter on your behalf with the information that you have provided.

Marketplace Consent *

By Checking This Box, I Hereby Provide Consent to Patrick Caldwell (Agent) 10175770, to enroll me and/or my family in a health insurance plan through the ACA Marketplace At No Cost to You. If I am already enrolled in the Marketplace with a plan, I request that Patrick Caldwell (Agent) 10175770 become my official agent of record and switch me to a richer health plan if one Is Available on the marketplace. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting Patrick Caldwell (Agent) 10175770 at 502-653-2090 or by email at patrick@pcahealthcaresoluions.com

By checking this box, I provide my express consent to Patrick Caldwell (Agent) 10175770 as my health Insurance agent and as my limited power of attorney to enroll me in a health insurance plan and to and to automatically enroll me in a plan at renewal. I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

AGREEMENTS, please read the attestations below and sign if you agree.

I agree to have my information used and retrieved from government data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from government data sources. I understand that I’m 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 don’t, I may face penalties, including the risk of losing my eligibility for 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. TAX ATTESTATION I understand that I’m not eligible for a premium tax credit if I’m 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 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 2023 tax year. I MUST FILE A FEDERAL INCOME RETURN FOR THE 2023 TAX YEAR. If I’m married at the end of 2023, 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 income tax return. I’ll claim a personal exemption deduction on my 2023 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 2023 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. PLEASE READ THE ATTESTATIONS BELOW BEFORE YOU SIGN AND SUBMIT YOUR APPLICATION: I know that I must tell the program I’ll be enrolled in if the information I listed on this application changes. I know I can make changes in my Marketplace account or by contacting Patrick Caldwell (Agent) at 1(502) 653-2090. 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 later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who is found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost. You consent to the use of an electronic signature to sign all forms presented to you by Patrick Caldwell (Agent) during the health insurance policy application process, unless and until you withdraw your consent to the use of electronic signatures by providing notice to the address below and agree that this consent is effective on the date that you affix your signature below. By signing below, you agree to be legally bound as if you had signed this form and other documents with a handwritten signature, and you acknowledge that you have reviewed and agree to the above terms and conditions. If you have any questions, please contact us at patrick@pcahealthcaresolutions.com. Please signify your agreement with the foregoing by signing below. I’m signing this application under penalty of perjury, which means I’ve provided true answers to all 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. You consent to the use of an electronic signature to sign all forms presented to you by Patrick Caldwell (Agent) during the health insurance policy application process, unless and until you withdraw your consent to the use of electronic signatures by providing notice to the address below and agree that this consent is effective on the date that you affix your signature below. By signing below, you agree to be legally bound as if you had signed this form and other documents with a handwritten signature, and you acknowledge that you have reviewed and agree to the above terms and conditions. If you have any questions, please contact Patrick Caldwell (Agent). Please signify your agreement with the foregoing by signing below. I hereby authorize Patrick Caldwell to sign the application for Federally Facilitated Exchange health insurance on my behalf, and to store my electronic signature affixed below for the purposes of doing so. I understand that at this time I have not yet applied for Federally Facilitated Exchange health insurance, and that Patrick Caldwell will be using the information and consents I provide herein to fill out, sign on my behalf, and submit the Federally Facilitated Exchange application. By pressing the submit button above (1) I understand that I am using an electronic signature to express written consent to receive emails, telephone calls, text messages, artificial or pre-recorded messages from Patrick Caldwell (Agent). (2) I agree to this website’s Privacy Policy (https://www.pcahealthcaresolutions.com) and Terms of Use (https://www.pcahealthcaresolutions.com). If you have questions about our Privacy Policy, please contact us at patrick@pcahealthcaresolutions.com. Do Not Sell My Info form here. For more information regarding these privacy matters, please refer to our Privacy Policy. Providing false information may subject you to liability. I understand that my consent is not required as a condition of purchase and that I may revoke my consent at any time.

I have read and agree to the terms above, and I attest that the personal information I have provided is true and correct *

ACA Application Signature

Clear