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Click here or scroll down to respond to this candidateCandidate's Name , LLCCandidate's Name NJ EnrollmentDisclosures:Candidate's Name Enrollment Disclosures: To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the New Jersey Marketplace to use my income data, including information from tax returns, for the next 5 years. New Jersey Marketplace will send me a notice, let me make any changes, and I can opt out at any time.I understand that Im not eligible for a premium tax credit if Im 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 New Jersey Marketplace to end my New Jersey Marketplace coverage and premium tax credit. If I dont, 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 Street Address tax year. If Im 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. Ill 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 New Jersey Marketplace, and whos 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 Ill be enrolled in if information I listed on this application changes. I know I can Generated by https://esignatures.io July 31, 2024 Page 1/4 make changes in my marketplace account or by calling the New Jersey Marketplace Call Center at 1-833-677-1010 (TTY 711). I know a change in my information could affect eligibility for member(s) of my household. If anyone on your application is enrolled in New Jersey Marketplace coverage and is later found to have other qualifying Candidate's Name or by contacting the New Jersey Marketplace directly. This written notice can be sent to docs@healthmarketsolution.com.I approve nj.gov/getcoverednj/ 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 Candidate's Name 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 Candidate's Name ' Terms of Service and Privacy Policy. https://www.healthmarketsolution.com/terms-and-conditions/ https://www.healthmarketsolution.com/privacy-policy/ Optional ConsentPage 2/4Candidate's Name NJ Enrollment Disclosures: Generated by https://esignatures.io July 31, 2024We 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 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 PHONE NUMBER AVAILABLE YESNOIf you would like to contact us, you may email us directly at EMAIL AVAILABLE or call our customer service line at PHONE NUMBER AVAILABLE with any questions you might have. Phone Number used on this call today:PHONE NUMBER AVAILABLEI 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:Lashawn DennisonPage 3/4Candidate's Name NJ Enrollment Disclosures: Generated by https://esignatures.io July 31, 2024Electronic SignaturesLashawn Dennison(digital representation of the signature)Lashawn DennisonMobile: PHONE NUMBER AVAILABLEJuly 31, 2024 17:31Audit trailJuly 31, 2024 17:30Contract is sent to Lashawn Dennison PHONE NUMBER AVAILABLEJuly 31, 2024 17:30Viewed by Lashawn DennisonJuly 31, 2024 17:30Mobile number verified Lashawn Dennison PHONE NUMBER AVAILABLE July 31, 2024 17:31Signed by Lashawn Dennison (IP: PHONE NUMBER AVAILABLEJuly 31, 2024 17:31Document finalizedID: 7a4167da-0772-4d66-99da-4e7f6a6f4f55Page 4/4Candidate's Name NJ Enrollment Disclosures: Generated by https://esignatures.io July 31, 2024 |
