Assured Health Group

Assured Health Group Enrollment 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. 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 my marketplace account or by calling the 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 April 02, 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. I also attest that from this day forward Assured Health Group, LLC. will be the agent of record for my healthcare.gov insurance plan with the marketplace and will only be replaced by another agent if written notice is submitted to Assured Health Group. This written notice can be sent to ad42k0@r.postjobfree.com. I approve Healthcare.gov access on my behalf and give permission to update my application throughout the year if needed.

I further give authorization to enroll me in a new health plan if my current health plan is discontinued by the insurance carrier.

Plans change every year. I give permission for you to assess my plan, compare it to the new plans that come out every year, and enroll me in a new plan during open enrollment if the coverage and benefits are better. In some cases, it may be necessary to verify the information you provided in order to complete your enrollment; I authorize Assured Health Group to submit the required documentation on my behalf based on the information that I have provided (which may include an income verification letter). In the future, it may be necessary to send you transactional SMS messages regarding your policy. You grant us permission to send you transactional SMS messages related to your policy and other products and services available under your policy.

I agree to Assured Health Group’s Terms of Service and Privacy Policy. https://assuredhealthins.com/terms-and-conditions/ https://assuredhealthins.com/privacy-policy/

Optional Consent

We also request your optional consent to send you marketing SMS messages and to contact you via telephone using an autodialer and/or prerecorded telephone messages, and your consent is not a condition of purchasing any goods or services. If you select “yes” then you agree to receive these optional marketing SMS text messages, autodialed calls, and Page 2/4

Assured Health Group Enrollment Disclosures:

Generated by https://esignatures.io April 02, 2024 prerecorded messages, at the number you provide, and agree that you understand that ordinary messaging and data rates may apply to your receipt of texts as well as your receipt of calls, and that you can revoke your consent at any time by replying STOP to any message or notifying us at our customer service line at 1-855-***-**** YES

NO

If you would like to contact us, you may email us directly at ad42k0@r.postjobfree.com or call our customer service line at 1-855-***-**** with any questions you might have. Phone Number used on this call today

470-***-****

I hereby acknowledge that I have read, agree to, and understand the above conditions (other than the optional consent, where I have indicated “yes” or “no” in the above optional consent section). Please type your Full Name. Schemeka Robinson

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Assured Health Group Enrollment Disclosures:

Generated by https://esignatures.io April 02, 2024 Electronic Signatures

Schemeka Robinson

Mobile: +1-470-***-****

April 02, 2024 10:41

Audit trail

April 02, 2024 10:40

Contract is sent to Schemeka Robinson +1-470-***-**** April 02, 2024 10:40

Viewed by Schemeka Robinson

April 02, 2024 10:40

Mobile number verified Schemeka Robinson +1-470-***-**** April 02, 2024 10:41

Signed by Schemeka Robinson (IP: 68.117.212.185)

April 02, 2024 10:41

Document finalized

ID: c2c112b6-b46c-4ab1-bc46-5d0725cff12b

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Assured Health Group Enrollment Disclosures:

Generated by https://esignatures.io April 02, 2024