AGENCY INFO:

Name of Agency: Peterson Insurance Solutions

Owner of Agency: Jennifer Peterson

National Producer Number (NPN): 20763803

Phone Number: 803-346-5848

Email Address: Jenn@PetersonInsuranceSolutions.com

I authorize Jennifer Peterson, owner of Peterson Insurance Solutions LLC, to advise and assist me with my Affordable Care Act Health Care Marketplace coverage. I consent to have Jennifer Peterson perform the following actions as directed by me on the following form or via other communications on my behalf:

• Conduct a search for any Healthcare Marketplace applications I may have through a Centers for Medicare & Medicaid Services approved Direct Enrollment or Enhanced Direct Enrollment system.
• Work on my behalf to apply for financial assistance or enroll in a Marketplace Qualified Health Plan (QHP).
• Contact the Marketplace Call Center to ask about the status of a Marketplace enrollment or make application changes.
• Discuss and share my confidential information with authorized personnel for the purpose of managing my plan and application.

By signing below, I acknowledge and agree to the above terms and authorize the aforementioned actions.

 

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 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 following tax year.

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 MUST FILE A FEDERAL INCOME RETURN FOR THE FOLLOWING TAX YEAR:

If I’m married at the end of of the 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 next federal income tax return. I’ll claim a personal exemption deduction on my next 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 next 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: 

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.