I attest that my household’s projected annual income for the benefit year in which I will receive financial assistance for my health plan is

• I acknowledge that the information provided on this form will only be used for purposes of eligibility determination for financial assistance. Covered California will keep this information private, as required by federal and California law.
• I understand that I must report income changes to Covered California within 30 days of the change because it may affect the amount of premium assistance (or tax credits) or the level of cost-sharing reduction for which I may qualify.
• I understand that if I receive too much premium assistance (or tax credits) during the benefit year, I will have to pay some or all of the excess premium assistance back to the Internal Revenue Service (IRS) when I file my federal income tax return for the benefit year.
• I declare under the penalty of perjury, under the laws of the state of California, that what I stated above is true and correct.

I fully understand its contents and the conditions of enrollment. I and my family have willingly disclosed all the requested personal and financial information to my agent for completing this application. I understand that I am solely responsible
for the accuracy of all personal and financial information that I have provided. I understand KCAL Insurance has no responsibility for any of my misstatements or concealment. Please read each numbered item and sign below. Your signature at the bottom indicates that you fully understand and agree to all information.

1. I understand that this health insurance does NOT include death benefits, as well as dental or vision coverage for adults age over 19.

2. I have clearly disclosed information on the application for all my family members who are claimed on my tax return form.

3. I have reviewed and confirmed everything I provided on the application is correct.

4. If I am offered group health insurance by my employer or my family member’s employer, I cannot receive any subsidies from Covered CA. Furthermore, I may possibly need to return all the subsidies I received by the end of the year.

5. If I am eligible for Medicare or already have coverage through other health plans but still applied through Covered CA, Covered CA has the right to deny my subsidy request or ask me to return all subsidies back when filing for taxes.

6. Covered CA will contact me if there is any missing information after the application is received. I need to provide it on time; otherwise, my application will be declined or canceled. I may not be eligible to apply for health insurance, my
application for any subsidies may be denied, or I may need to contact the county office to verify my family information.

7. Upon receiving the application, Covered CA will send me a confirmation about the plan and plan benefits that me and my family members are qualified for. If I don’t hear back from Covered CA, I will contact Covered CA directly at 1-800-300-1506

8. If my income or immigration status changes, it may affect the plan benefits and the premium assistance amount I qualify for. If I have health insurance through Covered CA, I need to report income or immigration status changes within 30 days from the change. If I have Medi-CAL, I need to report the change to the county office. KCAL Insurance Agency is unable to provide any Medi-CAL follow-up services.

9. If I need to change my contact information such as home address, I will contact KCAL Insurance Agency for any adjustment. If I want to cancel my insurance, I need to voluntarily contact Covered CA or KCAL Insurance 15 business days prior to the cancellation. Otherwise, my cancellation date cannot be effective on the 1st of the following month.

10. The final premium, tax credit and plan benefits will be decided by Covered CA after reviewing my application. I need to make sure that the premium has been successfully withdrawn on time by the insurance company before the policy
becomes active. If I don’t agree with the decision Covered California made, I can contact Covered CA to file an appeal.

11. I understand that if I am using an HMO plan, I can only assign a PCP after the insurance is effectuated. I need to contact my assigned PCP before conducting any service; if I am using a PPO or EPO plan, I need to go to in-network doctors, laboratories, and hospitals for related services in order to receive relevant plan benefits. If I am using Kaiser Insurance, I can only receive treatment at Kaiser Facilities unless going to the emergency room.

12. I understand that I need to read all letters received from Covered CA and the insurance company because they all contain very important information.

13. I understand that the insurance company must receive premium payments before the due date of every month in order to ensure my policy stays active. For terminations due to non-payment, the insurance company will send the owed balance amount to the collection agency.

14. I understand that the insurance company has the right to appoint a Collection Company to collect any unpaid premium.

15. I understand that I can only make changes to my plan or insurance company during the open enrollment period.

16. I understand that I may have to clear the balance for the non-paid canceled policy if I’d like to re-enroll through the same insurance company. The insurance carrier has the right to deny my new application if I refuse to pay.

17. I understand that whether I choose a Primary Care Provider (PCP) at the time of application, my first PCP is automatically assigned by the insurance carrier. If I wish to change providers, I need to contact KCAL Insurance Agency after receiving my insurance card.

18. I understand that I am obligated to check the status of automatic payments myself.

19. I understand that KCAL Insurance Agency takes no responsibility for any failed automatic payments that result in my policy being terminated and that I must contact KCAL Insurance Agency as soon as possible after the termination.