NEW OBAMACARE FORMS 2026

Consent for Marketplace Assistance

I consent to provide my personal and/or family information and give permission for Mr. Michael Bourdeau (NPN: 20400008) and KAVE SOLUTIONS INSURANCE AGENCY to assist me with my Marketplace application, enrollment, and ongoing account maintenance. The information collected will only be used for the purpose of obtaining healthcare coverage through the Marketplace.

This consent is valid for up to one (1) year from the date given unless revoked earlier. I understand I may revoke this consent at any time by notifying my agent in writing, by email, or by phone.

Your Agent: Mr. Michael Bourdeau
Agency: KAVE SOLUTIONS Insurance Agency
NPN: 20400008
Email: mrmichael@kavesolutions.com
Phone: (321)382-4490 (754)224-1022

Referred by / Refere pa:

Name and Phone

Name - Applicant / Main Person

First NameMiddle NameLast Name

Date Of Birth

Month-Date-Year

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Phone Number xxx-xxx-xxxx

SSN

XXX-XX-XXXX

Immigration Status

Email

example@example.com

Employment Status Income Information

Income - Applicant / Main Person

Job Name/ Occupation $$ MONTHLY - OR$$ YEARLY - OR$$$ NO INCOME / DONT QUALIFY

*** Spouse Info - (If Tax File Jointly)

First and LastDate of BirthSocial (If Applying)YES if Applying or NO

Spouse - Income ( If Tax File Jointly )

Name Job$$ Biweekly OR$$ Monthly OR$$ Yearly Income

Spouse- Immigration Status

Dependent # 1 - (Claim in Tax)

First and LastDate of BirthSocial Security #YES if Applying or NO

Dependent # 2 - (Claim in Tax)

First and LastDate of BirthSocial Security #YES if Applying or NO

Dependent # 3 - (Claim in Tax)

First and LastDate of BirthSocial Security # YES if Applying or NO

Dependent # 4 - (Claim in Tax)

First and LastDate of BirthSocial Security # YES if Applying or NO

Dependent # 5 - (Claim in Tax)

First and LastDate of BirthSocial Security # YES if Applying or NO

Best Time To Contact You

Important Notes

company request, dental or vision request, Zero dollar plan request, etc...

Agreements and Understanding:

I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, Children 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 I must file a federal income tax return for the 2026 tax year and If I’m married at the end of 2026, I must file a joint income tax return with my spouse. I expect that No one else will be able to claim me as a dependent on their 2026 federal income tax return. I’ll claim a personal exemption deduction on my 2026 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 these conditions of my tax status change, I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2026 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. I know that I must tell the program I’ll be enrolled in within 30 days if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). I know a change in my information could affect the eligibility for member(s) of my household.

I understand and agree to all the statements above. By signing this application, I certify under penalty of perjury that I have provided true and accurate answers to all questions to the best of my knowledge. I acknowledge that I may be subject to penalties under federal law if I intentionally provide false information.

I also consent to being contacted regarding additional services or offers that may benefit me.

Signature

Health Insurance (Obamacare) Consent form 2026