Consumer Consent and appliction Form

Consumer Application and Consent Form
I give Ellis Statom of Kelger Insurance Group LLC consent to conduct a search using approved Classic DE/EDE websites in the marketplace on my behalf. This consists of assisting with completing an eligibility application, plan selection, enrollment and ongoing account/enrollment maintenance.

By signing this form, I agree Ellis Statom has informed me of the functions, responsibilities, and role of agents in the marketplace which consists of creating, collecting, disclosing, accessing, maintaining, storing and/or use my personally identifiable information (PII) for the sole purpose of carrying out the roles and responsibilities of a licensed agent on the Federally Faciliated Marketplace.

By signing this form, I give permission to Ellis Statom to conduct the following activities:
- Searching for an existing Marketplace application
- Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or advanced tax credits to help pay for Marketplace Premiums
- Providing ongoing account maintenance and enrollment assistance as necessary
- Responding to inquiries from the Marketplace regarding my Marketplace application
My signature serves as acknowledgment that Ellis Statom is my agent of record and has been granted permission to assist with ongoing plan selection, enrollment and account/enrollment maintenance. I understand my consent remains in effect until I revoke it. This consent can be rovoked or modified at anytime with written consent and must be provided by email to estatom@att.net rescinding this agreement.

I give permission to Ellis Statom to serve as my health insurance agent or broker for myself and my entire household if applicable for the purposes of creating, collecting, disclosing, accessing, maintaining, storing and/or use my personally identifiable information (PII) for the sole purpose of carrying out the roles and responsibilities of a licensed agent on the Federally Faciliated Marketplace.

I understand that the Agent will not use or share my personally identifiable information(PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept privateand safe when collection, storing ans using my PII for the stated purposes above.

I understand that my consent remains in effect until I revoke it. I understand that these permissions and consent can be revoked or modified at anytime by notifying Ellis Statom via email at

I have reviewed the eligibility application information. The information in the eligibility application is accurate. Ellis Statom of Kelger Insurance Group LLC is the assisting broker.

All proposed plans have been explained to me and I accept and understand all cost, bennefits and responsibilities therein.
I agree to allow the Marketplace or Georgia Access to use my income data, including tax returns, for the next 5 years to make it easier to determine eligibility for help paying for coverage in future years. The Marketplace will send me a notice, let me make changes and I can opt out at any time.*

AgreeDisagree
I understand that I am not eligible for a premium tax credit if I am eligible for other qualifying health coverage like Medicaid, Children’s Health Insurance Program (CHIP), or a job-based health plan. If I qualify for other qualifying health coverage, I must notify the Marketplace or Georgia Access and end my Marketplace coverage and premium tax credit or the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because a premium tax credit will be paid on my behalf to reduce the cost of health coverage:

I must therefore file a federal income tax return for the 2026 tax year. If I am married at the end of 2026, I must file a joint tax return with my spouse. I understand that

I cannot be claimed as a dependent for tax year 2026 and must claim a personal exemption deduction on my 2026 federal income return for any individual listed as my dependent who is enrolled in coverage through the Marketplace.

I understand that if any of my information changes, it may impact my ability to get the premium tax credit.
I know that I must tell the program I’ll be enrolled in if the information listed on this application changes. I know I can make changes in my Marketplace or Georgia Access account by calling my agent and granting him access to speak with the Marketplace on my behalf. I know a change in my information could affect eligibility for member(s) of my household.*

AgreeDisagree
If anyone on your application is enrolled in Marketplace or Georgia Access coverage and is later found to have qualifying health coverage, the Marketplace will automatically end their Marketplace coverage.*

I agree to allow the Marketplace to end the Marketplace coverage of the people on my application in this situation.I don't give the Marketplace permission to end Marketplace coverage in this situation. I understand that the affected people on my application will no longer be eligible for financial help and must pay full cost for their Marketplace plan.
Consumer or Authorized Representative Signature*

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APPLICANT
EMPLOYER OR SELF EMPLOYED ANNUAL HOUSEHOLD INCOME*
Minimum Income requirements

household size

1. $18,000 5. $38,000

2. $24,500 6. $43,500

3. $27,000 7. $49,000

4. $33,500 8. $54,500
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A NUMBEREXPIRATION DATE
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IF NOT A CITIZEN PROVIDE A NUMBER

A NUMBEREXPIRATION DATE

DEPENDENTS

IF CLAIMED ON TAX RETURN OR GETTING INSURANCE
Name

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Name

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Name
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Consumer Application and Consent Form

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APPLICANT

SPOUSE

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