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Send A Request

I understand that I am not eligible for a premium tax credit if I am 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 Elite Legacy Group and/or the Marketplace to end my Marketplace coverage and premium tax credit. If I do not, the person who files taxes in my household may need to pay back my premium tax credit.

Before completing your enrollment, please review the following attestations:

I attest that no one applying for health coverage on this application is incarcerated.
I attest that no member on the enrollment application has group coverage offered to them.
I give permission to the marketplace to access my tax returns for up to 5 years to verify my income for subsidy purposes.
I agree to have my information used and retrieved from data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from data sources. However, if I revoke permission, I understand that I will be required to a complete federal application every year to confirm my income and subsidy eligibility. I understand that should the information listed on this application for enrollment change, it is my responsibility to update the information with the federal marketplace. I understand that I can make changes by accessing my marketplace account online or by calling 1-866-805-2506. I further understand that a change in my information could affect eligibility for members of my household.

I agree to allow HealthSherpa to submit my healthcare.gov financial assistance and health insurance application on my behalf.

I understand that changes may occur to my premium based on my subsidy eligibility results. Further, I authorize HealthSherpa and any Licensed Agent affiliated with BP Marketing to submit the application for enrollment and notify me of these changes via the email I provided on the application. I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period. If I don’t qualify, I may face penalties, including the risk of losing my eligibility for coverage.

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 in 2025 for the tax year of 2024.
If I'm married at the end of 2024, I must file a joint income tax return with my spouse.
I must report any income changes throughout the year to prevent any issues with taxes.

I also expect that:

I am not currently Enrolled in Medicare or any State Medicaid Program.
No one else will be able to claim me as a dependent on their 2024 Federal income tax return.
I will claim a personal exemption deduction on my 2024 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 2024 Federal Income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application.
If the income on my tax return is lower than the amount of income on my application, I may become eligible to get 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.

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 maybe subject to penalties under Federal law if I intentionally provide false information.

If your income is $0 (or less than the Federal Poverty Limit), you attest that your estimated income for 2024 will be at least the Federal Poverty Limit for your state and household requirements. If your income will be less than (or greater than) those limits, you agree to notify us or the marketplace of any changes or updates as soon as possible. Failure to notify us of any changes may result in your eligibility being affected.

I authorize and consent that Elite Legacy Group, LLC, Melodie Cole, 5301 Van Buren St. Hollywood, Fl 33021 or one of its affiliated licensed agents will be my agent of record for myself and my household, for the purpose of enrollment in a qualified Health Plan offered by the Federal Facilitated Marketplace. I authorize them to:

Search for an existing Marketplace application;
Submit and sign this application on my behalf and use 3rd party verification tools to confirm my eligibility requirements, such as date of birth, social security number, address, legal name etc, as well as update my existing marketplace application,
Provide ongoing maintenance and enrollment assistance, as necessary; or
Respond to inquiries from the Marketplace regarding my application.
and process my renewal applications unless I revoke this authorization.

I understand that the Agent will not use or share my personally identifiable information 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 understand that my consent and authorization remain in effect untiI I revoke it, and I may revoke or modify my consent at any time by sending a request to revoke consent to Melodie@EliteLegacyGroup.net that must be dated and signed.

By signing the document or filling out the form and attesting Yes, I am affirming that I agree to all the above statements. This permission is granted for me, my spouse or any other household member listed on the application in the plan that we have listed.

Purpose Statement: Registered agents and brokers assisting consumers apply for and enroll in Marketplace coverage must document consumer consent prior to accessing or updating their Marketplace information. CMS does not prescribe the manner in which agents and brokers must document consent. Instead, there are different formats that may be acceptable for agents and brokers to use to document consumer consent, such as via a recorded phone call, text message, email, electronic document with digital signatures, physical document with wet signatures, etc.

Frequently Asked Questions

What most people asked!

What is health insurance, and why is it important?

Health insurance is a financial protection plan that covers medical expenses. It's crucial because it ensures you can access healthcare services without bearing the full financial burden, providing peace of mind during unexpected medical situations.

How do I decide which health insurance plan is best for me and my family?

The right health insurance plan depends on your unique needs, budget, and preferences. Consider factors like healthcare needs, budget, preferred doctors and hospitals, and any specific medications you require. That's were our consultation come in as insurance experts for guidance.

What types of health insurance plans are available, and what are their differences?

Health insurance plans come in various forms, including Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Exclusive Provider Organization (EPO). They differ in terms of network restrictions, out-of-pocket costs, and referrals required for specialists. It's important to choose a plan that aligns with your preferences and needs.

How do I decide which health insurance plan is best for me and my family?

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How can I lower my health insurance premiums?

You can reduce health insurance premiums by opting for a plan with a higher deductible, maintaining a healthy lifestyle, and exploring subsidies or tax credits that may be available in your region. Comparing plans from different providers can also help you find cost-effective options.

What is life insurance, and why do I need it?

Life insurance is a contract that pays out a sum of money to your beneficiaries upon your death. It provides financial support to your loved ones, helping them cover expenses, debts, and maintain their quality of life after you're gone.

Can I have both health and life insurance simultaneously?

Yes, you can have both health and life insurance policies simultaneously. In fact, it's common for individuals to carry both types of coverage to ensure comprehensive financial protection.

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What is a waiting period in life insurance, and how does it affect my coverage?.

A waiting period is a specified time frame after purchasing a life insurance policy during which certain benefits may not be payable, especially for natural causes of death. The length of the waiting period can vary among policies, so it's essential to review the terms and conditions of your specific policy.

Can I change my health insurance or life insurance plan after I've purchased it?

The ability to change your health or life insurance plan depends on the terms and conditions of your policy and regional regulations. Typically, you can make changes during open enrollment periods or in specific life events, such as marriage or the birth of a child. It's advisable to consult with your insurance provider or a professional for guidance on plan adjustments.

(786) 977-8601