A copy of these attestations can be found linked at the bottom of this page.

You confirm that to the best of your knowledge your projected income for this year will meet or exceed the Federal Poverty Limit applicable to your state and household needs. You also agree to promptly inform us of any changes to your monthly income estimates provided herein. Failure to notify us of such changes may impact your eligibility status.

In certain instances, income verification may be necessary to finalize your enrollment. Should income verification be deemed necessary, you grant authorization to GoVine Insurance LLC to submit an income attestation letter on your behalf, utilizing the information provided by you.

If your income is $0 or falls below the Federal Poverty Limit, you affirm that your projected income for this year will meet or exceed the Federal Poverty Limit specific to your state and household needs. Should your income fluctuate below or above these thresholds, you agree to promptly inform us or the marketplace of any updates or changes. Failure to notify us of such changes may impact your eligibility status. By agreeing, you commit to informing GoVine Insurance LLC promptly in the event of any alterations to your estimated income for this year.

By providing my initials and signature below, I hereby grant consent and authorization to GoVine Insurance LLC, Agency NPN 20888409 to enroll myself and/or my family in a health insurance plan through the ACA Marketplace, with no associated costs to me. I authorize GoVine Insurance LLC to access my healthcare.gov account for the purposes of quoting, enrolling, and managing my health insurance coverage. In the event that I already have a plan, I request that GoVine Insurance LLC and its agents act as my Agent of Record and switch me to a more suitable plan if available. This consent shall remain valid unless revoked in writing, by emailing [email protected].

If your plan is changed, you acknowledge that your deductible and/or annual maximum out-of-pocket expenses will reset upon the commencement of your new policy. This will not apply or affect you if you are presently uninsured.

DISCLOSURES REGARDING LIMITED POWER OF ATTORNEY

The following limited power of attorney grants GoVine Insurance LLC the authority to manage decisions related to your health insurance. However, it does not authorize GoVine Insurance LLC or any other individual to make decisions regarding your medical care.

This limited power of attorney becomes effective immediately upon signing. If GoVine Insurance LLC is unable or unwilling to act on your behalf after you sign, we will notify you, and this power of attorney will be terminated.

Please review the limited power of attorney carefully. If you have any questions about the power of attorney or the authority granted to GoVine Insurance LLC, it is recommended that you seek legal advice before signing this form.

FORM OF LIMITED POWER OF ATTORNEY

I hereby grant GoVine Insurance LLC, Agency NPN 20888409, limited authority to undertake any and all actions necessary to select, procure, and maintain health insurance for myself and any dependents through the Federally-Facilitated Marketplace ("FFM"). This authority includes, but is not limited to, the following actions:

- Selecting a health plan on my behalf.

- Applying for and enrolling myself (and any dependents) in the chosen health plan.

- Modifying coverage by adding or removing individuals.

- Establishing or altering beneficiary or dependent designations.

- Updating contact information for myself, dependents, or beneficiaries.

- Providing updated information pertinent to eligibility for health insurance subsidies.

- Submitting additional documentation to a health insurance marketplace or exchange, such as proof of income and social security numbers.

- Maintaining the continuity of my health insurance coverage by renewing it periodically.

- Changing to a different health plan upon renewal if a more suitable option becomes available.

- Undertaking any other actions related to the health insurance as permitted by law.

The authority granted to GoVine Insurance LLC under this limited power of attorney will terminate upon my death, incapacity, or if I revoke the power of attorney in writing to GoVine Insurance LLC.

Any individual, including GoVine Insurance LLC, any web-broker acting on behalf of GoVine Insurance LLC for insurance applications, and the FFM, may rely on the validity of this limited power of attorney or a copy thereof, unless they are aware that it has been terminated.

By checking this box, I hereby give my express consent to GoVine Insurance LLC, granting GoVine Insurance LLC and/or its agents a limited power of attorney to enroll me in a health insurance plan and to automatically renew my enrollment at plan renewal.

By providing my contact information below, I consent to GoVine Insurance LLC contacting me via phone calls, text messages, and/or email, as necessary, regarding matters related to health insurance coverage and enrollment for the next 24 months.

Use of Personal Information:

I consent to the use and disclosure by GoVine Insurance LLC of (a) the personal information I have provided about myself and others in the questionnaire above, and (b) any other personal information about myself or the other individuals listed above which may be obtained by GoVine Insurance LLC from government data sources, for purposes of applying for health insurance coverage through the Federally Facilitated Exchange (the “Marketplace”) and for any other purposes disclosed in GoVine Insurance LLC’s Privacy Policy.

I agree to these websites: Privacy Policy and Terms of Service. If you have questions about our Privacy Policy, please Contact Us. California residents exercising their “right to know” or “right to deletion” can click here to make a request online or contact us. Each request is subject to verification. California and Nevada residents exercising the right to opt out of the sale of their data should access our Do Not Sell My Info form. For more information regarding these privacy matters, please refer to our Privacy Policy.

Eligibility:

I understand that I am required to provide true and complete answers to the questions posed above and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If the information provided by me is not true and complete, I may face penalties, including the risk of losing my eligibility for coverage. I know that I must inform GoVine Insurance LLC if information I have provided changes. I understand that I can update my information in my Marketplace account or by contacting GoVine Insurance LLC. I know a change in my information could affect eligibility for member(s) of my household. I understand that if anyone I identified above as needing coverage is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who is found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.

Renewal of Coverage:

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.

Tax Attestation:

I understand that I am not eligible for a premium tax credit if I am found eligible for other qualifying health coverage, like Medicaid, the 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 do not, 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 current tax year.

If I’m married at the end of this year, 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 federal income tax return for this year. I’ll claim a personal exemption deduction on my 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 federal income tax return for this year, 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 understand the foregoing does not constitute tax advice provided by GoVine Insurance LLC to me, and that should I have any questions regarding any tax credits for which I may be eligible, my tax returns, or any other related tax matters, I should consult a qualified tax advisor prior to enrolling in health insurance coverage provided via the Marketplace.

Electronic Signatures and Communications:

I consent to the use of an electronic signature to sign all forms presented to me by GoVine Insurance LLC during the health insurance enrollment process, including, without limitation, to signing this form below, unless and until I withdraw my consent to the use of electronic signatures by providing notice to the address below. I agree that this consent is effective on the date that I affix my signature below and by supplying my initials above. By signing below, I agree to be legally bound as if I had signed this form and other documents with a handwritten signature, and I acknowledge that I have reviewed and I agree to the above terms and conditions. By signing below, I am providing my express written consent to receive emails, telephone calls, text messages, and artificial or pre-recorded messages from GoVine Insurance LLC regarding this form and any health insurance coverage applied for on my behalf by GoVine Insurance LLC.

I understand that at this time I have not yet applied for Federally Facilitated Exchange health insurance, and that GoVine Insurance LLC will be using the information and consents I provide herein to fill out, sign on my behalf, and submit the Federally Facilitated Exchange application. If you have any questions, please contact GoVine Insurance LLC at [email protected]. This form is used to help to find insurance for you and your family.

The information provided must be accurate for the subsidies to be accurate. Failure to provide the correct information could result in claims being invalidated or the termination of your insurance policy. By submitting an application, you confirm that the information is accurate to the best of your knowledge.