Check Eligibility For $0 Health Insurance Plan + Premium Tax Credit!

By filling out and submitting this application review and consent, you are attesting and agreeing to all of the following statements. If you don't agree with any of the statements below, please exit this page and do not continue.

By submitting this form, it signifies my electronic signature, I give permission to work on my behalf. In the case the marketplace is requesting documents, I give permission to the agent to submit documents on my behalf with details I have provided on this application form. When open enrollment begins on November 1st of each year, I authorize the agent to auto-renew my insurance policy and remain agent of record to ensure my coverage does not lapse. If another agent goes into my application and changes the agent of record, I give permission to the agent to go back in and be listed as agent of record. By submitting this form I give full consent and grant my permission to Harona Osborne to serve as the health insurance Agent for myself and my entire household for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. I authorize this licensed Agent to view and use the confidential information provided by me to search for existing Marketplace applications, complete applications for eligibility and enrollment in various Qualified Health Plans, provide necessary account maintenance and enrollment assistance on an ongoing basis and respond to inquires from the Marketplace on my behalf and the behalf of my entire household regarding my application. I understand and attest that my personally identifiable information (PII) will not be used or shared for any other purposes than what is stated above. I have reviewed and I confirm that the information I have supplied for my Marketplace eligibility and enrollment application is true and accurate to the best of my Knowledge. I understand that I am not to disclose additional personal or health information beyond what is for my eligibility and enrollment. My consent remains in effect until I revoke it. To make modifications or revoke my consent, I can contact my Agent at hosborne@marketplaceoptions.com

Renewal of coverage To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.

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 know that I must tell the program I’ll be enrolled in 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.

Tax attestation Please read the attestations below and select a response for each statement. I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: I must file a federal income tax return for the 2025 tax year. If I’m married at the end of 2025, I must file a joint income tax return with my spouse. I also expect that: No one else will be able to claim me as a dependent on their 2025 federal income tax return. I’ll claim a personal exemption deduction on my 2025 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 the above changes: I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2025 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.