ACKNOWLEDGMENTS

By clicking ‘Submit’, I agree to have my information used and retrieved from government data sources for this application. I also attest I have the authority to give permission and act on behalf of all other peoples listed in this application. I am giving my express permission for a health insurance agent from YIRParters.com to act on behalf of everyone listed in this application. By doing this I am granting permission to operate on behalf of everyone listed in the application in regards to the procurement of any health, dental, vision plans I may need. I understand that I am required to provide true answers and that I may be required to provide additional information including proof of my eligibility for a special enrollment, if I qualify. If I don’t, I may face penalties including the risk of losing my eligibility for coverage. To make it easier to determine my eligibility for helping for future coverage in the years to come I agree to allow the marketplace to use my income data, including information from tax returns, for the next five years. The marketplace may send me a notice or contact me at any time for any reason, let me make any changes, and I can opt out at any time.

TAX ATTESTATION

I understand that I’m 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 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 tax return for the 2023 tax year. By agreeing to this I am also agreeing to file a tax return for the year 2023 and every year thereafter I am enrolled in the affordable care act and receive a healthcare credit. If I married at the end of 2023, 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 2023 federal tax return. I’ll claim a personal exemption deduction on my 2023 federal tax return for any individual listed on this application as my dependent who is enrolled in coverage through this marketplace, and their 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 2023 federal tax income return the Internal Revenue Service (IRS) may 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 added to my tax return. 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 taxes.

I affirm that no one on the application has been denied for Medicaid in the past 90 days.

If I receive a policy, I will email support@yirpartners.com whenever anyone listed on the policy has a change in income.

I understand YIRParters.com may find dental and vision plans that I and other applicants are eligible for. The Acknowledgements, Terms & Conditions, and Privacy Policy listed on YIRParters.com apply.

In some cases it may be necessary to verify my income. By clicking SUBMIT I expressly consent for an YIRParters.com representative to submit an income attestation letter on my behalf with the information I provided.

By clicking SUBMIT I provide express consent to enroll me and/or my family in a health insurance plan through the ACA marketplace at no cost. If I already have a plan, I authorize a licensed YIRParters.com representative to replace my Agent on Record.

By clicking SUBMIT I provide express consent to a YIRParters.com licensed representative to check my plan every year to make sure I am in the lowest plan available to me.

By clicking SUBMIT, I provide express consent and grant my assigned agent a limited power of attorney to enroll me in a health insurance plan and to automatically enroll me in a plan at renewal.

BEFORE CLICKING SUBMIT PLEASE READ

I know that I must tell the program I’ll be enrolled in if the information I listed on this application changes. I know I can make changes in my marketplace account by logging into healthcare.gov. I also understand that a change in my information can affect eligibility for member(s) of my household. If anyone on my application is enrolled in marketplace coverage and is later found to have other qualifying health coverage like Medicaid, Medicare or 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 agree that clicking SUBMIT is in lieu of a handwritten signature and will act as my ‘electronic signature’ for ALL forms presented to me by YIRParters.com during the health insurance policy application and binding process unless and until I withdraw my consent to the use of electronic signatures by providing notice to the email address below. I agree that this consent is effective on the date that I clicked SUBMIT. By clicking SUBMIT, 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 agreed to all terms in the Acknowledgements, Terms & Conditions, and Privacy Policy.

By clicking SUBMIT I am signing this application under penalty of perjury, which means I provided true answers to all 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.

By clicking SUBMIT I hereby authorize YIRParters.com to sign the application for federally facilitated exchange health insurance on my behalf. Clicking SUBMIT acts as my electronic signature; for purposes of doing so I understand that at this time I have not yet applied for federally facilitated exchange health insurance and that YIRParters.com will be using the information and consent that I provide here and to fill out, sign on my behalf, and submit the federally facilitated exchange application. Providing false information may subject me to liability. I understand that my consent is not required as a condition to purchase and that I may revoke my consent at any time.

1. I understand that this action acts as express written consent to receive emails, telephone calls, text messages, artificial or pre-recorded messages, direct mailers, or any other means of communication YIRParters.com deems necessary from YIRParters.com.
2. I agree to the website & form Acknowledgments, Terms & Conditions, and Privacy Policy listed on this form and at YIRParters.com.

If you have any questions about the Acknowledgement, Term & Conditions, and/or Privacy Policy please contact us at support@yirpartners.com