Application

ACA Tax Acknowledgement *

By checking here, I acknowledge I must file a tax return for any previous years I have received ACA subsidies/tax credits and any future years for which carriers receive the advanced premium tax credit. I understand this subsidy is not a refundable tax credit, grocery card, or spendable incentive card of any kind. Carriers may offer some incentives to promote healthy lifestyles and preventative appointments. Failure to file taxes can result in my coverage being revoked by CMS and tax penalties. I also understand I should consult with a tax professional regarding my estimated annual income to ensure I do not owe back any subsidies.

Consent to Search the Marketplace *

I consent and give my permission to Jacob Radcliffe, NPN 21324262 to serve as the health insurance agent 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 Agent 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 such as checking the status of eligibility applications throughout the year to help resolve data matching issues using approved DE/EDE websites approved by CMS. 4) Responding to inquiries from the Marketplace regarding my Marketplace application. I consent to be called to perform a three-way call with CMS to help change my plan and agent of record if I am currently in the marketplace. I understand that by signing this consent form that my consent is only revoked with your written or verbal request. I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent 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 provide for entry on my Marketplace eligibility and enrollment application will be 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 Agent beyond what is required on the application for eligibility and enrollment purposes. I consent to allow my new Agent of Record (AOR) to send letters, emails, and phone calls on my behalf for the purpose of contacting and revoking any previous AOR from accessing my private information or attempting to change AOR or plans without my express verbal or verifiable consent. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by email or phone. This consent form, call recordings, SMS, and emails will be saved for 10 years. Name of Primary Writing Agent: Jacob Radcliffe; Agent National Producer Number: 21324262; Phone Number: 239-350-4100; Email Address: [email protected]. By checking this box, signing this form, and clicking submit I agree to the terms & conditions and privacy policy on mycuratedinsurance.com. By clicking Submit, I hereby grant consent for Jacob Radcliffe with My Curated Insurance NPN 21324262 to contact me by phone at the number above even if my phone number is listed on a Do Not Call Registry and permit to be contacted from an automated calling system, receive promotional phone or SMS/MMS messages, appointment reminder calls or reminder SMS messages, AI SMS messages, AI generated phone calls, live transfer call requests, customer service calls, and to receive live or pre-recorded recorded voicemail messages with or without the use of AI. I hereby grant consent to be contacted by email at the email address above or provided on a phone call. I hereby grant consent to receive mail at the address above or provided on a phone call. I understand that my agreement to be contacted is not a condition of purchasing any property, goods or services. I understand that I can reply STOP to SMS or unsubscribe from emails to stop communications at any time on specific messaging platforms or channels. To opt-out of future phone calls you may indicate so by phone, email, SMS. Message and data rates may apply. Message frequency varies.