2026 ACA/Covered CA - Renewal / Change Authorization Form

Renewal / Change Authorization

2025-2026 Covered California / Affordable Care Act CA License #0773817
Policy Holder Name*
First Name
Last Name
Date of Birth*

MonthDayYear
Date
Email*
Phone Number*
Primary Residence Zip Code*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Renew as is?*

YesNo
Taxable household size in 2026:*
Estimated Household Income for 2026:*
Primary Household Member Name
Primary Household Member Income
How do they make their primary income?*

EmploymentSelf EmploymentInvestment/InterestRetirementOther
Primary Household Member Source of Income
Employer Address*
Include Street Address, City, and Zip
2nd Household Member Name
2nd Household Member Income
How do they make their primary income?*

EmploymentSelf EmploymentInvestment/InterestRetirementOther
2nd Household Member Source of Income
Employer Address*
Include Street Address, City, and Zip
3rd Household Member Name
3rd Household Member Income
How do they make their primary income?*

EmploymentSelf EmploymentInvestment/InterestRetirementOther
Employer Address
Include Street Address, City, and Zip
4th Household Member Name
4th Household Member Income
How do they make their primary income?*

EmploymentSelf EmploymentInvestment/InterestRetirementOther
Employer Address
Include Street Address, City, and Zip
5th Household Member Name
5th Household Member Income
6th Household Member Name
6th Household Member Income
7th Household Member Name
7th Household Member Income
8th Household Member Name
8th Household Member Income
I would like to compare plans:
What change would you like to make?

Change plan type (PPO, EPO, HMO)Different deductible/copayReduce premiumInclude my doctors
Current Plan
Current Monthly Premium
I would like to change to a:

PPOEPOHMO
List any Doctors that need to be included in your network. Please include contact and location info.
Is your Current Plan through Covered California?

YesNoI don't know
Is your plan premium subsidized by the state?

YesNoI don't know
Proof of Income

Accepted: Pay stub, W-2, 1099, Tax Return, Employer/Benefit Letter
Cancelof
I authorize Stevens & Associates Insurance Agency, Inc. to make the above changes for me and agree to discuss any of the changes requested above. I understand that changes cannot be made to my plan until I speak with my agent. I understand that any changes to my income, failure to file a tax return, or changes to my plan could increase/decrease my premium, and may affect any government subsidy I may be receiving.
I have been advised by the agent that any subsidy received to reduce my monthly premium is an Advanced Premium Tax Credit, based on the estimated income for 2026. The Advanced Premium Tax Credit is a sliding scale and may be zero if income is over 400% of the Federal Poverty Level. The Advance Premium Tax Credit will be adjusted at the end of the year based on my actual income.
I understand that if my income changes I must report the change to Covered California; and my tax credit will be adjusted accordingly. If my income increases, I will have to pay the difference at tax time. It is important that I stay current with any income changes so I have an idea of how much I will owe at tax time. I understand that any change in my household income should be reported to Covered California immediately.
I give permission for Stevens & Associates Insurance Agency to check whether my household can continue receiving financial help to lower monthly health insurance costs in 2026. This may include sharing information with agencies such as the IRS and the Social Security Administration.

Clear
Your consent lets us verify your eligibility for financial help. Please choose the number of years you’d like this consent to last:*

1 Year2 Years3 Years4 Years5 Years
Heads up: Without consent, you may lose financial help for 2026 and pay the full plan cost starting January 1, 2026.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Renewal / Change Authorization

I would like to compare plans: