Consent

I authorize Kate Spilsbury to be my health insurance agent for myself and my household. I also authorize the following agents to support my enrollment, renewal, and ongoing account maintenance as needed:

• Worley Richards, NPN: 7918700

• Michael Wakefield, NPN: 8082802

This consent allows Kate Spilsbury, Worley Richards, and Michael Wakefield of Health Wealth Simplified LLC dba Mere Benefits to enroll me, or my family, in a Qualified Health Plan on the Federally Facilitated Marketplace. By agreeing to this, I give permission for these agents and assistors to use my confidential information for the following purposes:

• Search for an existing Marketplace application.

• Complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs.

• Provide ongoing account maintenance and enrollment assistance.

• Respond to inquiries from the Marketplace regarding my application.

All agents will keep my personal information private and secure, using it only for the purposes listed above. I confirm that the information I provide on my application will be accurate to the best of my knowledge. I understand that I am not obligated to share additional personal information beyond what is required for the application. I can revoke or modify my consent at any time by emailing info@merebenefits.com.

I acknowledge your request to enroll me in the most suitable health plan available based on your expertise, which may be a $0 monthly plan premium. If zero premium plans are unavailable, I authorize you to enroll me in the next best available plan. I grant you access to my healthcare.gov account for submitting necessary information. By signing below, I confirm my understanding and agreement to the terms outlined in this attestation.

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 2026 tax year. If I’m married at the end of 2026, 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 2026 federal income tax return. I’ll claim a personal exemption deduction on my 2026 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 2026 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application.

AGENT OF RECORD

Kate Spilsbury, NPN: 9527400
Agents: Worley Richards, NPN: 7918700; Michael Wakefield, NPN: 8082802
Phone Number: (904) 654-5450
Email Address: info@merebenefits.com

By signing below, I confirm my understanding and agreement to the terms outlined in this attestation, and I grant the above agent and assistors access to my healthcare.gov account for submitting necessary information.

Consent

I authorize Michael Wakefield to be my health insurance agent for myself and my household. This allows Michael Wakefield to enroll me, or my family, in a Qualified Health Plan on the Federally Facilitated Marketplace. By agreeing to this, I give permission for Michael Wakefield to use my confidential information for the following purposes:

• Search for an existing Marketplace application.

• Complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs.

• Provide ongoing account maintenance and enrollment assistance.

• Respond to inquiries from the Marketplace regarding my application. The Agent will keep my personal information private and secure, using it only for the purposes listed above. I confirm that the information I provide on my application will be accurate to the best of my knowledge. I understand that I am not obligated to share additional personal information beyond what is required for the application. I can revoke or modify my consent at any time by emailing michael@merebenefits.com

  I acknowledge your request to enroll me in the most suitable health plan available based on your expertise, which may be a $0 monthly plan premium. If zero premium plans are unavailable, I authorize you to enroll me in the next best available plan. I grant you access to my healthcare.gov account for submitting necessary information. By signing below, I confirm my understanding and agreement to the terms outlined in this attestation.

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 2026 tax year. I MUST FILE A FEDERAL INCOME RETURN FOR THE 2026 TAX YEAR. If I’m married at the end of 2026, 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 2026 federal income tax return. I’ll claim a personal exemption deduction on my 2026 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and who's 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 2026 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I

Agent of Record: Michael Wakefield

NPN: 8082802

Phone Number: (904) 654-5450

Email Address: michael@merebenefits.com

Consent

I authorize Worley Richards to be my health insurance agent for myself and my household. This allows Worley Richards to enroll me, or my family, in a Qualified Health Plan on the Federally Facilitated Marketplace. By agreeing to this, I give permission for Worley Richards to use my confidential information for the following purposes:

1. Search for an existing Marketplace application.

2. Complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs.

3. Provide ongoing account maintenance and enrollment assistance.

4. Respond to inquiries from the Marketplace regarding my application. The Agent will keep my personal information private and secure, using it only for the purposes listed above. I confirm that the information I provide on my application will be accurate to the best of my knowledge. I understand that I am not obligated to share additional personal information beyond what is required for the application. I can revoke or modify my consent at any time by emailing worley@merebenefits.com

   I acknowledge your request to enroll me in the most suitable health plan available based on your expertise, which may be a $0 monthly plan premium. If zero premium plans are unavailable, I authorize you to enroll me in the next best available plan. I grant you access to my healthcare.gov account for submitting necessary information. By signing below, I confirm my understanding and agreement to the terms outlined in this attestation.

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 2026 tax year. I MUST FILE A FEDERAL INCOME RETURN FOR THE 2026 TAX YEAR. If I’m married at the end of 2026, 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 2026 federal income tax return. I’ll claim a personal exemption deduction on my 2026 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and who's 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 2026 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I

Agent of Record: Worley Richards

NPN: 7918700

Phone Number: (602) 606-7785

Email Address: worley@merebenefits.com

Mere Benefits is a DBA of Health Wealth Simplified LLC, managed by Kate Spilsbury, Licensed Insurance Agent #9527400

Please click HERE for a list of helpful questions and talking points you can use when contacting your provider directly.

NOTE:

• Social Security Number of ALL the household members on the application will be required AT THE TIME OF THE APPLICATION

Employer Group Health Benefits

Are you or any household member offered group health benefits through an employer?

© Copyright 2025. Mere Benefits.

All Right Reserved