Authorization for Completion of Marketplace Enrollment Form Your agent has almost completed your Marketplace enrollment. You just need to review and approve everything that was entered on your behalf. Your agent has emailed you a copy of your Marketplace enrollment application, Marketplace eligibility notice, and health plan selection. Please review the information for accuracy. If you are satisfied with the information, please type your name in full below to provide your electronic signature, which will authorize your agent to finalize your Marketplace enrollment. By signing below you also understand and agree that: The information on your application is accurate and true to the best of your knowledge, You want to enroll in the health plan shown for the monthly premium displayed, The Marketplace will use your income data, including information from your tax return for the next five years, to simplify re-determining your eligibility in the future, You will not be eligible for a premium tax credit if you are found eligible for other qualifying health coverage, like Medicaid or a job-based health plan, You must notify your agent if you become eligible for other qualifying coverage so they may end your Marketplace coverage and premium tax credit, In order to qualify for a premium tax credit you must file a federal income tax return, and if married, you must file a joint return with your spouse, No one else will be able to claim you as a dependent on their federal income tax return You must reconcile any premium tax credit on your federal income tax return and that the IRS will determine if you received too little, too much, or just enough tax credit, In the event you received too much premium tax credit, you may have to repay some or all of the tax credit and if you received too little tax credit, you may receive the owed tax credit as part of your tax refund or have it applied to your income tax liability, If any of your information changes, it may impact your eligibility for Marketplace coverage and the premium tax credit You must notify your agent or the Health Insurance Marketplace within 30 days if any of your information changes If you are signing as an authorized representative of the application, please include your name and relationship to the applicant. Examples of authorized representatives can include parents or guardians of minor children, or individuals with Power of Attorney (POA) for another person. Please type your Full Name to use as your Electronic Signature:(Required) Date(Required) MM slash DD slash YYYY Are you signing as an Authorized Representative?(Required) Yes No What is you relationship to the Applicant?(Required)
