ACA: 2026 Health Insurance Marketplace Final Attestation Form

2026 Health Insurance Marketplace Final Attestation Form

Thank You For Choosing DarkHorse Insurance Solutions To Help You With Your ACA/Marketplace Healthcare Choices.
Client Information

First NameLast Name
Email
example@example.com
Carrier and Plan Chosen (example: Blue Cross and Blue Shield of Texas Blue Advantage Bronze HMO 204)
Estimated Projected Income for 2026
Assisting Agent Name

First NameLast Name
Assisting Agent NPN
I attest that I have personally went over my plan selection and application answers with my agent. I agree with the answers to all questions and have verified the plan chosen to be the correct plan applied for. I agree with the total household income amount stated on my 2026 Application for marketplace insurance. I agree to have my agent submit my insurance application on my behalf. I have given permission to DarkHorse Insurance Solutions, LLC DBA DarkHorse Insurance Solutions and its Agents and Employees to service my marketplace insurance.
Signature
Agent Compensation Disclosure:
By signing below, I acknowledge that my licensed insurance agent and/or their agency may receive compensation from the insurance company for assisting with my enrollment. This compensation is paid by the insurance company—not by me—and is based solely on my enrollment in the selected plan.

Compensation may range from $0 to $30 per person per month, depending on the state and insurance carrier, with an average of about $20 per member per month. Some carriers may also offer small performance bonuses to agents based on the total number of enrollments completed with that carrier.

Please note that certain insurance companies have chosen not to compensate agents for servicing their plans. As a result, our agency is unable to offer coverage or ongoing service for those specific plans in affected areas.

If you would like more details about the compensation received for a specific plan, please contact our office. We will research and provide the most current information available; however, commission structures are changing frequently (sometimes weekly) and generally not in favor of agents, so exact amounts are not listed here.

(Certain states, such as New Mexico, require additional signed consent specific to agent compensation. While our agency is not currently licensed in New Mexico, we include this disclosure for transparency and compliance with federal and carrier standards.)

I consent to the agent receiving compensation from the carrier for my enrollment.
Signature
Date

MonthDayYear
Date
I attest that I am the writing agent for the client above: I agree that I have gone over all the policy details with the client answered all questions about the policy and answered the questions using the information that the client provided to me for the marketplace application that I submitted.
Name

Last Name
Should be Empty: