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Customers have opted-in via check box on website, form submission or key word. I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (678) 662-7098 for assistance. Your data will NOT be sold or distributed to third parties. You can reply STOP to unsubscribe at any time.

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 (Georgia Access, etc) 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’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 2025 tax year. If I’m married at the end of 2025, 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 2025 federal income tax return. I’ll claim a personal exemption deduction on my 2025 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 2025 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 within 30 days of 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 1-800-318-2596 (TTY: 1-855-889-4325). I know a change in my information could affect eligibility for member(s) of my household. If anyone on your application is enrolled in Marketplace coverage and is also found to have Medicare coverage, the Marketplace will automatically end their Marketplace plan coverage. They will get a notice before Marketplace terminates their coverage in case they need to keep it or make changes. During all the months of overlapping coverage, they're responsible for paying the full cost for the Marketplace plan premium and covered services.

Definitions of Terms

Agent: A licensed professional authorized to assist with health plan selection, enrollment, and account support.
PII (Personally Identifiable Information): Any data that can identify you, such as your name, address, phone number, date of birth, Social Security Number, and financial information.
Marketplace: The Federally Facilitated Marketplace (FFM) or state exchange where qualified health plans are offered.
Consent: Your permission allowing an agent to access and use your information for stated purposes.

I give my permission to Rain Young (Uranius Young)/PNJ Financial Solutions | PNJ Insurance Solutions 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.

AGENT CONSENT FORM