I must provide accurate information for eligibility and may need to provide proof. If I’m enrolled in Marketplace coverage and later found to have other qualifying health coverage, my Marketplace plan will be terminated automatically. I permit the Marketplace to use my income data for 5 years to determine my eligibility for assistance. I’m not eligible for a premium tax credit if I have other qualifying health coverage. I must inform the Marketplace if I become eligible for other coverage to avoid repayment of the premium tax credit. I must file a federal income tax return for the 2024 tax year. If I’m married at the end of 2024, I must file a joint income tax return with my spouse. No one else will be able to claim me as a dependent. I understand, this does not constitute tax advice, and I should consult a tax advisor for tax-related matters.
I consent to receive electronic notices and use electronic signatures during enrollment.
I confirm I’m authorized for the provided phone number and agree to receive marketing calls/messages.
Derek Bennett NPN 18389656 or Health Connect Solutions inc will use my information to complete the Marketplace application on my behalf I’m signing 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.
