Before completing your enrollment, please review the following attestation. I attest that no one applying for health coverage on this application is incarcerated. I attest that no member on the enrollment application has group coverage offered to them. I give permission to the marketplace to access my tax returns for up to 5 years to verify my income for subsidy purposes. I agree to have my information used and retrieved from data sources for this application. I have consent for all people I will list on the application for their information to be retrieved and used from data sources. However, if I revoke permission, I understand that I will be required to a complete federal application every year to confirm my income and subsidy eligibility. I understand that should the information listed on this application for enrollment change, it is my responsibility to update the information with the federal marketplace. I understand that I can make changes by accessing my marketplace account online or by calling 1-800-318-2596. I further understand that a change in my information could affect eligibility for members of my household. I agree to submit my healthcare.gov financial assistance and health insurance application on my behalf. I understand that changes may occur to my premium based on my subsidy eligibility results. Further, I authorize any Licensed Agent affiliated with BP Marketing to submit the application for enrollment and notify me of these changes via the email I provided on the application. I understand that I am 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 do not qualify, I may face penalties, including the risk of losing my eligibility for coverage. I authorize and consent to Wise Owl Insurance Group LLC, Oscar Petrassi and their affiliates will be my agent of record. I authorize them to submit and sign this application on my behalf and use 3rd party verification tools to confirm my eligibility requirements, such as date of birth, social security number, address, legal name etc., as well as update my existing marketplace application, and process my renewal applications unless I revoke this authorization. This Consent and Authorization will Remain in place unless rescinded. You request that we make sure we are the Agent of Record on your account each month until consent is revoked. We will also make sure your application is up to date for Open Enrollment each plan year. If your current plan is discontinued, we will enroll you in the best plan you qualify for. If your eligibility changes, you are required to let us know. This permission may be rescinded at any time by email. 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 in 2024 for the tax year of 2023. • If I am married at the end of 2023, I must file a joint income tax return with my spouse. I also expect that: • I am not currently Enrolled in Medicare or any State Medicaid Program. • No one else will be able to claim me as a dependent on their 2023 federal income tax return. • I will claim a personal exemption deduction on my 2023 federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through this marketplace and who is premium for coverage is paid in whole or in part by advance payments. • If any of the above changes, I understand that it may impact my ability to get a 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. • 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. I agree that I have read this, and I give my permission to Paul w/WOI Group on today’s date to serve as my broker for myself and my household, for the purpose of enrollment in a qualified Health Plan offered by the Federal Facilitated Marketplace. I consent to allow the above-mentioned agent to view use my confidential information for the following purposes: 1. Search for an existing Marketplace Plan. 2. Complete and application for eligibility and enrollment in a Marketplace Plan. 3. Provide ongoing maintenance and enrollment assistance; or 4. Respond to inquiries from the Marketplace regarding my application. 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 if my estimated income for 2023 changes. If the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax. I agree to this application under penalty of perjury, which means I have 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. By clicking the button/checking the box/attesting yes/signing you are agreeing to this document, you attest to the accuracy of all the statements on this page. You revoke this consent by sending us an email at paul@wiseowlinsurancegroup.com. I agree to have a check and make sure I am the agent of record at the end of each month. I do not consent to another agent taking over as my Agent or Record until I revoke it by email paul@wiseowlinsurancegroup.com. You agree that your income estimation would fall in the range below based on your tax household size.
