February **, ****

Advantage Health LLC

ACA Disclosures

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 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 2024 tax year. If I’m married at the end of 2024, 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 2024 federal income tax return. I’ll 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. 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.

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 myMarketplace account or by calling Marketplace Call Center at 1-800-***-**** (TTY: 1-855-889- 4325). I know a change in my information could affect eligibility for member(s) of my household. Generated by https://esignatures.io February 07, 2024 Page 1/4 If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or Children's Health Insurance Program (CHIP)), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost. 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.

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. Check the boxes below if you agree:

I give my permission to Coleman Pollock, Advantage Health, 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: Searching for an existing Marketplace application, 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, Providing ongoing account maintenance and enrollment assistance, as necessary; or, Responding to inquiries from the Marketplace regarding my Marketplace application. 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 understand that my consent remains in effect for three years from this date or until I revoke it, and I may revoke or modify my consent at any time by sending notice to ad3geb@r.postjobfree.com.

In some cases, it may be necessary to verify your income. If income verification is required in order to complete your enrollment, do you authorize Advantage Health to submit an income attestation letter on your behalf with the information that you have provided?

I understand and agree that in the event I change insurance carriers, I am responsible for promptly notifying Advantage Health, as failure to do so may result in my coverage reverting to the originally selected plan in certain cases.

Page 2/4

ACA Disclosures Advantage Health LLC

Generated by https://esignatures.io February 07, 2024 Zip Code

76164

I hereby acknowledge that I have read and understood the above conditions. Page 3/4

ACA Disclosures Advantage Health LLC

Generated by https://esignatures.io February 07, 2024 Electronic Signatures

Johnny Espinoza

(digital representation of the signature)

Johnny Espinoza

Mobile: +1-817-***-****

February 07, 2024 12:50

Audit trail

February 07, 2024 12:49

Contract is sent to Johnny Espinoza +1-817-***-****

February 07, 2024 12:49

Viewed by Johnny Espinoza

February 07, 2024 12:49

Mobile number verified Johnny Espinoza +1-817-***-**** February 07, 2024 12:50

Signed by Johnny Espinoza (IP: 68.185.214.243)

February 07, 2024 12:50

Document finalized

ID: 78e5d56f-0b70-47b9-a0e6-fc7f73cd1268

Page 4/4

ACA Disclosures Advantage Health LLC

Generated by https://esignatures.io February 07, 2024

Contact this candidate