2025 Open Enrollment Consent and Application

Applicant
First Priority Benefits Taking care of your Insurance needs. If you have any questions please call Antnie Rockwell at 678-697-5780.
Income verification date

MonthDayYear
Date
How did you find out about us
Full Name*
Birthdate*

MonthDayYear
DOB
SSN*
eg. 123-45-6789
Sex*
Spouse Full Name
Birthdate

MonthDayYear
DOB
SSN
e.g., 123-45-6789
Sex
Permanent street address no PO Boxes*
City*
County*
State*
Zip*
Cell phone*
home phone
Email*
example@example.com
Mailing Address if different

Mailing address if different

Street Address Line 2

CityState

Zip

Applicant
Employer*
Put unemployed if unemployed
Projected Annual Income 2025*
Have you smoked in the last six months?*
If your company offers insurance, how much is it a month?
Employer Phone Number
Please enter a valid phone number.
If not a Citizen, please provide Citizenship #

Spouse
Employer
Put unemployed if unemployed
Projected Annual Income 2025
Have you smoked in the last six months?
If your company offers insurance, how much is it a month?
Employer Phone Number
Please enter a valid phone number.
If not a Citizen, please provide Citizenship #

Dependents
Full Name
Birthdate
DOB
SSN
e.g., 123-45-6789
Full Name
Birthdate
DOB
SSN
e.g., 123-45-6789
Full Name
Birthdate
DOB
SSN
e.g., 123-45-6789
My signature serves as acknowledgment that Antnie Rockwell is my agent of record and has been granted permission to assist with ongoing plan selection, enrollment and account/enrollment maintenance. understand my consent remains in effect until | revoke it. This consent can be rovoked or modified at anytime with written consent and must be provided by email to antnie@firstprioritybenefitsllo rescinding this agreement.
I give Antnie Rockwell of First Priority Benefits 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 the Antnie Rockwell 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.

| give permission to Antnie Rockwell 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. | 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. 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 Antnie Rockwell via email at antnie@firstprioritybenefitsllc.
I agree to allow the Marketplace 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 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 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
| 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 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 2023 tax year. If I am married at the end of 2023, I must file a joint tax return with my spouse.

| understand that I cannot be claimed as a dependent for tax year 2023 and must claim a personal exemption deduction on my 2023 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.
If anyone on your application is enrolled in Marketplace 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.
Signature

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AGENT
Antnie Rockwell
DATE*

MonthDayYear
Date

FOR AGENTS USE ONLY
Carrier
Monthly Cost
Type of plan
Application date

MonthDayYear
Date
Application
Projected start date

MonthDayYear
Date
Return to agent Antnie Rockwell 678-697-5780 (GA License # 3458064) email: rockwellant@gmail.com
Should be Empty:

Applicant