MAIN APPLICANT INFORMATION

ADDRESS INFORMATION

HOUSEHOLD INFORMATION

I attest that from this day forward Gary Veach will be the agent of record for my healthcare.gov insurance plan with the marketplace and will only be replaced by another agent if written notice is submitted to him.

Dependent Information

Socials are only needed if dependent is applying for insurance

If you have 6 or more dependents, it is necessary to schedule a phone meeting in order to enroll everyone. Access the calendar for Gary Veach, using the link below. Choose a time on the calendar, that works for best for you.

PLAN CHOICE

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 2022 tax year.

I MUST FILE A FEDERAL INCOME RETURN FOR THE 2022 TAX YEAR.

If I’m married at the end of 2022, 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 2022 federal income tax return. I’ll claim a personal exemption deduction on my 2022 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 2022 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 ATTESTATIONS BELOW BEFORE YOU SIGN AND SUBMIT YOUR APPLICATION:

I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling, emailing or texting Gary Veach at (863) 272-7744. 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. You consent to the use of an electronic signature to sign all forms presented to you by Gary Veach 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 enroll@Best-LifeHealthPlans.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 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. You consent to the use of an electronic signature to sign all forms presented to you by Gary Veach 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 Gary Veach at enroll@Best-LifeHealthPlans.com. Please signify your agreement with the foregoing by signing below. I hereby authorize Gary Veach to sign the application for Federally Facilitated Exchange health insurance on my behalf, and to store my electronic signature affixed below for purposes of doing so. I understand that at this time I have not yet applied for Federally Facilitated Exchange health insurance, and that Gary Veach will be using the information and consent I provide herein to fill out, sign on my behalf, and submit to the Federally Facilitated Exchange application.