Agreements

Please scroll down to read the attestations below and sign if you agree.

This Health Insurance Brokerage Services Agreement (the "Agreement") is made and entered into as of this 08/23/2025 and lasts until I email [email protected] to rescind permission, by and between:

Douglas (NPN: 4591057) representing Affordable Care Insurance Brokers, Health Insurance Broker hereinafter referred to as the "Broker" or " Agent"

and

​ with address BirthDay# , email , phone​ ,

a person who is Submitting, Applying, Enrolling or Renew the application for ACA Insurance hereinafter referred to as "I" or "Client".

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 Douglas and his team 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, Medicare, 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 Douglas at [email protected] 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 I'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:

By consenting to this agreement, I authorize Douglas, NPN number 4591057, and/or his team to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

1. Searching for my existing Marketplace applications, becoming AOR of my effective application, and switching plans to the best plan available.

2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums.

3. Providing ongoing account maintenance and enrollment assistance, as necessary; or

4. Responding to inquiries from the Marketplace regarding my Marketplace application.

5. Auto-renew my plan into the best available plan for the next calendar year.

I know at any time I may rescind permission to access or use my data by emailing Douglas at [email protected]

and rescinding marketplace permission.

I know that I must tell Douglas if the information I listed on this application changes. I know I can make changes in my Marketplace account or by emailing Douglas at [email protected]. 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's found to have other qualifying coverage won't stay enrolled in Marketplace coverage and have to pay full cost.

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