By clicking the checkbox below, I hereby provide consent and authorization to My Health Insurance, LLC and Best Policy, LLC and/or its affiliates to submit my estimated income within a range of 20% above or below the estimated income that I provided on this application. I also provide consent and authorization to My Health Insurance, LLC and Best Policy, LLC and/or its affiliates to submit an income verification letter on my behalf if required by the marketplace.

By clicking “I Agree”, I am providing my electronic signature expressly authorizing My Health Insurance, LLC and Best Policy, LLC and/or its affiliate to contact me by email, phone or text (including an automatic dialing system or artificial/pre-recorded voice) at the home or cell phone number above. I understand I am not required to sign/agree to this as a condition to purchase. I give my permission to My Health Insurance, LLC and Best Policy, LLC and/or its affiliates to serve as the health insurance agency, agent, and/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 agency, agent, and/or broker to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of 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 premiums; 3- Providing ongoing account maintenance and enrollment assistance, as necessary; or 4- Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the agency, agent, and/or broker will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agency, agent, and/or broker 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 provided for entry on my Marketplace eligibility and enrollment application is 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 Agency, agent, and/or broker 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 emailing [email protected]

Disclaimer for Health Insurance Applications
Please note that due to circumstances beyond our control, we cannot guarantee the processing time for your application. However, we strive to handle your application as promptly as possible. If we require further clarification or additional information, one of our knowledgeable agents will contact you using the method you specified in your application.
We are committed to meeting your healthcare and ancillary insurance needs and aim to become the agency you are proud to recommend to your family and friends. If a prompt submission of your application is necessary or you have any questions before submitting your application, please contact us at 385-308-5251 (available from 9 AM to 9 PM Eastern) or via email at [email protected].

If another agent goes into your application and changes the agent of record, we will no longer have access to your policy. Should that happen, do you give permission to our agency to go back in and be listed as agent of record? | Renewal Authorization: Open Enrollment begins Nov 1st of every year. This is when we need to re-enroll your health policy with us. Do you authorize us to auto-renew your insurance policy and change your plan to a different company if needed to ensure your plan remains $0 even if there is a different network of doctors? This allows us to remain agent of record and ensure your coverage does not lapse. | Tax Attestation - Please confirm that you: (1) Agree to allow the Marketplace to use your income data, including information from tax returns, for the next 5 years; (2) understand that you are not eligible for a premium tax credit if found eligible for other qualifying health coverage, such as Medicaid, CHIP, or a job-based health plan; (3) understand that if you become eligible for other qualifying health coverage, you must contact the Marketplace to end your coverage and premium tax credit; (4) understand if the income on your tax return is higher than the amount of income on your application, you may owe additional federal income tax. I acknowledge that to participate in the Affordable Care Act program, I am required to file taxes for any year in which I have been enrolled. Failure to do so may result in loss of future eligibility

I have reviewed the above application information and attest to its accuracy, You agree that you have provided true answers to all of the questions to the best of your knowledge, and you know you may be subject to penalties under federal law if you intentionally provide false information. You attest that your estimated income for 2024 will be at least the Federal Poverty Limit for your state and household requirements . You agree to notify us as soon as you become aware of any changes to expected income per month that you provided above. Failure to notify us of any changes may result in your eligibility being affected. A Best Policy or My Health Insurance licensed agent will call you as we process your enrollment. You authorize Best Policy or My Health Insurance to submit an application on your behalf even if we cannot reach you immediately.