Essential Benefits Group 2025 Open Enrollment Consent and Application

2025 Consent & Application Form

Air, food, water — and health. Essentials you can’t live without. At Essential Benefits, we make sure coverage is one less thing you have to worry about. Call us at 470-334-3376 if you have questions about this application or the services we provide.

Applicant Information
Today's Date

MonthDayYear
Date
How did you find out about us?*
First Name*
Last Name*
DOB*

MonthDayYear
Date of Birth
Are you a U.S. citizen?*

YesNo
SSN*
eg. 123-45-6789
Immigration Document Number (if not a U.S. citizen)
Examples: A-Number, I-94 Arrival/Departure Record, or USCIS ID.
Sex*
Permanent Street Address*
No P.O. Boxes
City*
State*
Zip*
County*
Cell phone*
Home phone
Email*
example@example.com
Mailing Address if different

Mailing address if different from permanent address

Street Address Line 2

CityCity, State

Zip

Qualifying Questions
Employer*
Enter unemployed if unemployed
Employer Phone Number
Please enter a valid phone number.
Projected Annual Income 2025*
What is your total income for 2025 (actual or expected)?
If your company offers insurance, how much is it a month?
Have you smoked in the last six months?*
Do you have a spouse?*

YesNo
Are you claiming any dependents on your taxes for 2025?*

YesNo

Spouse Information
List your spouse’s details, even if you don’t plan to add them to coverage. If you are legally separated, you can skip this section.
Spouse Full Name
Birthdate

MonthDayYear
DOB
SSN
e.g., 123-45-6789
Sex
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.
Would you like to add coverage for your spouse?*

YesNo

Dependents
List your dependent’s details, even if you don’t plan to add them to coverage.
Full Name
Birthdate
DOB
SSN
e.g., 123-45-6789
Sex
Full Name
Birthdate
DOB
SSN
e.g., 123-45-6789
Sex
Full Name
Birthdate
DOB
SSN
e.g., 123-45-6789
Sex
Would you like to add coverage for your dependent(s)?*

YesNo

Privacy & Authorization Agreement
My signature serves as acknowledgment that Tati Burkins 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 revoked or modified at anytime with written consent and must be provided by email to essentialhealth365@gmail.com rescinding this agreement.

I give Tati Burkins of Essential Benefits Group 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 that Tati Burkins 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 using 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 give permission to Tati Burkins 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 private and safe when collection, storing and 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 Tati Burkins via email at essentialhealth365@gmail.com.
I agree to allow the Marketplace to use my income data, including tax return information, for up to the next 5 years to help determine my eligibility for financial assistance with coverage. I understand I will receive a notice each year, can update my information, and may opt out at any time.*

AgreeDisagree
I understand that I must notify the program I’m enrolled in if any of the information on this application changes. I may update my information by authorizing my agent to speak with the Marketplace on my behalf. I understand that changes to my information may affect eligibility for me and/or members of my household.*

AgreeDisagree
I understand that I am not eligible for a premium tax credit if I qualify for other health coverage, such as Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. If I become eligible for other health coverage, I must notify the Marketplace and end my Marketplace coverage with premium tax credits. Otherwise, the person who files taxes in my household may have to repay the credit.

If I qualify for a premium tax credit, I understand that because the credit will be paid on my behalf to lower the cost of coverage, I must file a federal income tax return for the 2025 tax year. If I am married at the end of 2025, and want to keep the premium tax credit, I must file a joint return with my spouse.

I understand that I cannot be claimed as a dependent on someone else’s 2025 federal tax return if I want to receive a premium tax credit. I must also correctly claim any dependents I list on this application on my 2025 federal tax return. I understand that if any of my information changes, it may affect my eligibility for the premium tax credit.
If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage, the Marketplace may automatically end their Marketplace coverage. Do you agree?*

I agree to allow the Marketplace to end coverage for the affected people in this situation.I do not agree. I understand that if the affected people on my application qualified for financial assistance, they will no longer be eligible and must pay the full cost of their Marketplace plan.
Signature

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AGENT
Tati Burkins
DATE*

MonthDayYear
Date