Use of Personal Information:
I consent to the use and disclosure by GoVine Insurance LLC of (a) the personal information I have provided about myself and others in the questionnaire above, and (b) any other personal information about myself or the other individuals listed above which may be obtained by GoVine Insurance LLC from government data sources, for purposes of applying for health insurance coverage through the Federally Facilitated Exchange (the “Marketplace”) and for any other purposes disclosed in GoVine Insurance LLC’s Privacy Policy.
I agree to these websites: Privacy Policy and Terms of Service. If you have questions about our Privacy Policy, please Contact Us. California residents exercising their “right to know” or “right to deletion” can click here to make a request online or contact us. Each request is subject to verification. California and Nevada residents exercising the right to opt out of the sale of their data should access our Do Not Sell My Info form. For more information regarding these privacy matters, please refer to our Privacy Policy.
Eligibility:
I understand that I am 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 know that I must inform GoVine Insurance LLC if information I have provided changes. I understand that I can update my information in my Marketplace account or by contacting GoVine Insurance LLC. I know a change in my information could affect eligibility for member(s) of my household. 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. 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.
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 am not eligible for a premium tax credit if I am 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 do not, 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 current tax year.
If I’m married at the end of this year, 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 federal income tax return for this year. I’ll claim a personal exemption deduction on my 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 federal income tax return for this year, 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.
I understand the foregoing does not constitute tax advice provided by GoVine 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 Signatures and Communications:
I consent to the use of an electronic signature to sign all forms presented to me by GoVine Insurance LLC during the health insurance enrollment process, including, without limitation, to signing this form below, unless and until I withdraw my consent to the use of electronic signatures by providing notice to the address below. I agree that this consent is effective on the date that I affix my signature below and by supplying my initials above. 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 I agree to the above terms and conditions. By signing below, I am providing my express written consent to receive emails, telephone calls, text messages, and artificial or pre-recorded messages from GoVine Insurance LLC regarding this form and any health insurance coverage applied for on my behalf by GoVine Insurance LLC.
I understand that at this time I have not yet applied for Federally Facilitated Exchange health insurance, and that GoVine Insurance LLC will be using the information and consents I provide herein to fill out, sign on my behalf, and submit the Federally Facilitated Exchange application. If you have any questions, please contact GoVine Insurance LLC at [email protected]. This form is used to help to find insurance for you and your family.
The information provided must be accurate for the subsidies to be accurate. Failure to provide the correct information could result in claims being invalidated or the termination of your insurance policy. By submitting an application, you confirm that the information is accurate to the best of your knowledge.