HEALTH INSURANCE APPLICATION

AUTHORIZATION/RELEASEI hereby grant permission to Sunset Insurance Group LLC ("SIG"), its affiliates, and selected agentsto access my family's marketplace, healthcare.gov, Medicare, and Medicaid accounts for the purpose of enrolling me in a the next best available healthplan. By signing this application, I acknowledge that I understand that SIG may switch me to a better plan if one is available and that if I am already onthe best plan, SIG may become my agent of record from this point forward, unless I notify SIG in writing of the change.I understand that my information will be used and retrieved from government data sources for this application, and I have obtained consent from allpeople listed on this application for their information to be retrieved and used from government data sources. I acknowledge that it is my responsibilityto provide true and accurate answers and that I may be asked to provide additional information, including proof of my eligibility for a Special EnrollmentPeriod if I qualify. I understand that failure to provide true and accurate information may result in penalties, including the risk of losing my eligibility forcoverage.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 five years. The Marketplace will send me a notice and allow me to make any changes, and I can optout at any time.If I am currently covered by Medicare, Medicaid, Disability or receiving Unemployment Benefits, I understand that enrolling for health insurancethrough the Marketplace may affect my current benefits.I understand that I am not eligible for a premium tax credit if I am found eligible for other qualifying health coverage, such as Medicaid, the Children'sHealth Insurance Program (CHIP), or a job-based health plan. I acknowledge that if I become eligible for other qualifying health coverage, I mustcontact the Marketplace to end my Marketplace coverage and premium tax credit. If I fail to do so, the person who files taxes in my household mayneed to pay back my premium tax credit. I also understand that because the premium tax credit will be paid on my behalf to reduce the cost of healthcoverage for myself and/or my dependents, I must file a federal income tax return for every tax year I am receiving health insurance through theMarketplace. Therefore, I agree to file a federal income tax return for every year I am on Marketplace insurance.If I am married at the end of each year, I am on Marketplace insurance; I must file a joint income tax return with my spouse. I also expect that no oneelse will be able to claim me as a dependent on their 2023 federal tax return for an individual listed on my application as my dependent who is enrolledin coverage through the Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.I acknowledge that if any of the above information changes, it may impact my ability to get the premium tax credit. I also understand that when I file myfederal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application, and I maybe 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 onmy application, I may owe additional federal tax income.I grant SIG a limited power of attorney to help me get enrolled in a Marketplace health insurance plan or another affordable healthcare plan. I alsorequest that SIG use this limited power of attorney to automatically assist me in a plan for renewal on an annual basis. If Healthcare.gov requiresincome verification or any other documents on Marketplace application, I grant SIG permission to submit those documents and an income verificationestimation.I hereby grant my consent to SIG to collect my personal information, including but not limited to my ID, Social Security Card, Birth Certificate, Passport,Immigration form, and any other personal documents that may be necessary to facilitate my enrollment in healthcare insurance through theMarketplace.Furthermore, I authorize SIG to obtain and utilize my personal information, including my photograph, voice, copy of Driver's License, Green Card, Visa,Naturalization Documents, Social Security Card, Birth Certificate, for the sole purpose of verifying my identity and citizenship.By affixing my electronic signature to this application, I acknowledge and agree that I am expressly authorizing SIG to contact me at the number,address, and email address provided with this application or to obtain additional information for such purpose, via live, prerecorded, or auto-dialedcalls, text messages, emails, for a period of 5 years.I further agree that upon the execution of my electronic application through SIG, I grant permission to resubmit and copy and paste my signature on mybehalf into the agent's electronic portal/website to assist me in applying for healthcare insurance.Moreover, I understand that it is my responsibility to provide proof of income, citizenship, non-incarceration, and any additional information as may berequired by government entities.I acknowledge that I am signing this application under the penalty of perjury, and therefore, affirm that all answers provided to the best of myknowledgeare true and accurate. I also acknowledge that providing false information intentionally may subject me to penalties under federal law. By signing below, you agree that all the information provided by you in this application is true and accurate.

Name of Agency: Sunset Insurance Group LLC Agency

National Producer Number: 21552407

Owner of Agency: Rita Proctor

Email Address: Rita@MySunsetInsurance.com

Phone Number: 941-363-1367

Eligibility Verification Notice

By signing this form, you agree that you have given a Licensed Agent at Sunset Insurance Group LLC, verbal and signed permission to submit your application for eligibility on your behalf to the HealthCare Marketplace for health care coverage and that you have received and reviewed your Eligibility Verification Notice before finalizing your plan selection.

Applicants Name: {name}

Agents Name: RITA PROCTOR

 

 

 

 

I, {name}, give my permission to RITA PROCTOR
 (“Agent”) to serve as the health insurance Agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following

1. Searching for an existing Marketplace application

2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premium

3. Providing ongoing account maintenance and enrollment assistance, as necessary

4. Responding to inquiries from the Marketplace regarding my application
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 collecting, storing, and using my PII for the stated purposes above I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to
the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes.
I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my Agent.

Primary Writing Agent Agency or Assistor - RITA PROCTOR / SUNSET INSURANCE GROUP LLC

Agent National Producer - 19313904

Phone number: 941-363-1367
Email address: RITA@MYSUNSETINSURANCE.COM
Name of Agency or Assistor: SUNSET INSURANCE GROUP LLC

NPN: 21552407
Owner of Agency: RITA PROCTOR Phone: 941-780-5245 Email: RITA@MYSUNSETINSURANCE.COM

Name of primary household contact: {name}

Authorized representative (if applicable): ____________________________

 

Phone number: {phoneNumber}

Email address:  {emailAddress}

 Rita@MySunsetInsurance.com NPN 19313904 - 941-363-1367

Sunset Insurance Group LLC 21552407 Rita Proctor 941-780-5245