UPDATED | OBAMACARE FORMS

Health Insurance Quote Application - (New)

We will contact you within 24 hours
Disclosure:

I give perrmission to Tahisha Olibrice (Agent), my 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 or State Based Exchange (SBE). By consenting to this agreement, I authorize the Agent to view and use the confidential information provided by me in writing, electronically or by phone on the following:

- Searching for an existing Marketplace or SBE application
- Completing an application for eligibility and enrollment in a Marketplace or SBE Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace or SBE premiums
- Providing ongoing account maintenance and enrollment assistance, as necessary
- Responding to inquiries from the Marketplace or SBE 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, safe and used for the stated purposes above.

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.

Agent name: Tahisha Olibrice Agent, NPN: 21524465, Phone: (561)785-3937 , Agency: T&C insurance and Financial Group LLc , Email: tcinsurancegroup17@gmail.com

I also agree to be contacted for other marketing offers or services.
Refferal Rep. OR Authorized Rep.
Name and Phone
Name - Applicant / Main Person

First NameMiddle NameLast Name
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearMonth-Date-Year
Phone Number
Phone Number xxx-xxx-xxxx
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN
XXX-XX-XXXX
Immigration Status (Main Applicant)
Email
example@example.com
HOW DO YOU FILE TAXES?
Employment / Job Status / Income Information
Income / - Applicant / Main Person

Job Name/ Occupation $$ MONTHLY - OR$$ YEARLY - OR$$ NO INCOME / DONT QUALIFY for APTC
*** 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$$ MONTHLY - OR $$ YEARLY - OR$$ NO INCOME / DONT QUALIFY for APTC
Spouse Immigration Status (Main Applicant)
Dependent # 1 - (Claim in Tax)

First and LastDate of BirthSocial (If Applying)YES if Applying or NO
Dependent # 2 - (Claim in Tax)

First and LastDate of BirthSocial (If Applying)YES if Applying or NO
Dependent # 3 - (Claim in Tax)

First and LastDate of BirthSocial (If Applying)YES if Applying or NO
Dependent # 4 - (Claim in Tax)

First and LastDate of BirthSocial (If Applying)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's 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 2027 tax year and If I’m married at the end of 2027, 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 2027 federal income tax return. I’ll claim a personal exemption deduction on my 2027 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 2027 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 eligibility for member(s) of my household.

If you understand and agree to all the statements above, please sign this application under penalty of perjury, which means I've provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.
Signature
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