I consent to the use and retrieval of my information from government data sources for the purposes of this application. I confirm that I have obtained the necessary consent from all individuals listed on the application for their information to be retrieved and used from government data sources.

I agree to have my information used and retrieved from government data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from government data sources. Any PII we collect is used to help you enroll in a Marketplace Qualified Health Plan (QHP).

I authorize Clover Health Group, LLC and or any of their licensed agents permission to conduct a search on my behalf using approved Classic Direct Enrollment/ Enhanced Direct Enrollment websites in the marketplace. Assist with completing an eligibility application, assist with plan selection and enrollment, and assist with ongoing account/enrollment maintenance.

I authorize that I currently do not have Medicare, Medicaid, an employer policy, or VA benefits (I understand that I will NOT qualify for Obamacare subsidy if I qualify for Medicaid/Medicare/ employer or VA plan. 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 2023 tax year and If I’m married at the end of 2023, I must file a joint income tax return with my spouse.

I acknowledge that I am obligated to provide accurate responses and may be requested to provide additional information, including evidence of my eligibility for a Special Enrollment Period, if applicable. Failure to comply may result in penalties, including the potential loss of my eligibility for coverage.

To facilitate the determination of my future eligibility for assistance in paying for coverage, I authorize the Marketplace to access my income data, including information obtained from tax returns, for the next five years. The Marketplace will provide notice of any changes and allow me to make adjustments, and I retain the option to opt out at any time.

I acknowledge that I am responsible for informing the program I am enrolled in if any information listed on this application changes. I understand that I can make changes to my Marketplace account and that any change in my information may affect the eligibility of members of my household.

If any individual listed on my application is enrolled in Marketplace coverage and subsequently found to have other qualifying health coverage such as Medicare, Medicaid, or CHIP, their Marketplace plan coverage will be automatically terminated by the Marketplace. This is to ensure that individuals with other qualifying coverage are not enrolled in Marketplace coverage and required to pay the full cost. By signing below, I agree to the use of an electronic signature to sign all forms presented to me by Clover Health Group, LLC during the health insurance policy application process, unless and until I withdraw my consent to the use of electronic signatures by providing notice to the address below, and I confirm that this consent is effective on the date that I affix my signature below. I acknowledge that by signing below, I am legally bound as if I had signed this form and other documents with a handwritten signature, and I have reviewed and agree to the above terms and conditions. If I have any questions, I can contact Clover Health Group, LLC at service@healthplanadmin.com. Please indicate your agreement with the foregoing by signing below.

I am signing this application under penalty of perjury, which means that I have provided true answers to all questions to the best of my knowledge. I understand that intentionally providing false information may subject me to penalties under federal law. By signing below, I agree to the use of an electronic signature to sign all forms presented to me by Clover Health Group, LLC during the health insurance policy application process, unless and until I withdraw my consent to the use of electronic signatures by providing notice to the address below, and I confirm that this consent is effective on the date that I affix my signature below. I acknowledge that by signing below, I am legally bound as if I had signed this form and other documents with a handwritten signature, and I have reviewed and agree to the above terms and conditions. If I have any questions, I can contact Clover Health Group, LLC at service@healthplanadmin.com. Please indicate your agreement with the foregoing by signing below.

I hereby authorize Clover Health Group, LLC to sign the application for Federally Facilitated Exchange health insurance on my behalf and to store my electronic signature affixed below for this purpose. I understand that I have not yet applied for Federally Facilitated Exchange health insurance and that Clover Health Group, LLC will use the information and consents I provide to fill out, sign on my behalf, and submit the Federally Facilitated Exchange application.

I understand that if I have other qualifying health coverage such as Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan, I may not be eligible for a premium tax credit. If I become eligible for other qualifying health coverage, I will inform the Marketplace to end my Marketplace coverage and premium tax credit, or I may risk having the person who files taxes in my household pay back my premium tax credit.

I understand changes in income may impact my ability to get the premium tax credit. Failure to notify us of any changes may result in your eligibility being affected. I also understand that when I file my 2023 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 acknowledge that in order to receive the premium tax credit to reduce the cost of health coverage for myself and/or my dependents, I must file a federal income tax return for the 2022 tax year.

In the event that I am married by the end of 2022, I am required to file a joint income tax return with my spouse. Additionally, I understand that I cannot be claimed as a dependent on anyone else's 2022 federal income tax return. For any dependent listed on my application 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, I will claim a personal exemption deduction on my 2022 federal income tax return.

If any of the above circumstances change I am aware that my eligibility for the premium tax credit could be affected and that the income reported on my 2022 federal income tax return will be compared to the income on my application by the Internal Revenue Service (IRS). If my income on the tax return is less than the income on my application, I may qualify for an additional premium tax credit. Conversely, if my income on the tax return is more than the income on my application, I may be required to pay extra federal income tax.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.