Please include all sources of income for each person in your tax household. Your tax household includes everyone you claim as a dependent on your tax return, even if they have separate insurance. Income that should be counted includes:

• Wages and salaries before taxes (include tips and bonuses)

• Self-employment income (after business deductions)

• Unemployment benefits

• Social Security benefits

• Rental or investment income

For guidance, you can refer to your most recent tax return. This amount will generally be similar to Line 11 on Form 1040 if your income is expected to be close to that amount. If you’re unsure about specific income details, please consult a CPA for assistance.

• For more information on how to project your income, please click HERE to check the guide

In order to enroll you we must be able to verify your identity through healthcare.gov all data provided is 100% secure and encrypted

NOTE:

• Social Security Number of ALL the household members on the application will be required AT THE TIME OF THE APPLICATION

Consent

I authorize Kate Spilsbury to be my health insurance agent for myself and my household. This consent allows Kate Spilsbury to assist me with my application and enrollment in a Qualified Health Plan on the Federally Facilitated Marketplace.
By agreeing to this, I give permission for Kate Spilsbury to use my confidential information for the following purposes:

1. Search for an existing Marketplace application.

2. Prepare and complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs, using only the information I provide.

3. Provide ongoing account maintenance and enrollment assistance.

4. Respond to Marketplace inquiries regarding my application in order to resolve issues or complete required steps.

5. Access my Healthcare.gov account solely to submit or update information with my knowledge and based on information I provide.

Important Acknowledgements

• I understand that no plan will ever be selected, changed, or submitted without my explicit verbal or written approval.

• All enrollment decisions will be reviewed and confirmed by me during my appointment.

• I must be present and actively participating in the enrollment meeting for my plan to be submitted.

• My agent cannot advise me on what income to report. I am responsible for providing accurate income and household information to the best of my knowledge.

• My personal information will be kept private and secure and used only for the purposes outlined in this consent.

• I am not required to share information beyond what is necessary for the application.

• I may revoke or modify this consent at any time by emailing [email protected], and revoking consent will not affect my eligibility for coverage.

By signing below, I confirm my understanding of and agreement to the terms outlined in this attestation.
Agent of Record: Kate Spilsbury
 NPN: 9527400
 Phone Number: (904) 654-5450
 Email Address: [email protected]

Consent

I authorize Worley Richards to be my health insurance agent for myself and my household. This consent allows Worley Richards to assist me with my application and enrollment in a Qualified Health Plan on the Federally Facilitated Marketplace.

By agreeing to this, I give permission for Worley Richards to use my confidential information for the following purposes:

1. Search for an existing Marketplace application.

2. Prepare and complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs, using only the information I provide.

3. Provide ongoing account maintenance and enrollment assistance.

4. Respond to Marketplace inquiries regarding my application in order to resolve issues or complete required steps.

5. Access my Healthcare.gov account solely to submit or update information with my knowledge and based on information I provide.

Important Acknowledgements

• I understand that no plan will ever be selected, changed, or submitted without my explicit verbal or written approval.

• All enrollment decisions will be reviewed and confirmed by me during my appointment.

• I must be present and actively participating in the enrollment meeting for my plan to be submitted.

• My agent cannot advise me on what income to report. I am responsible for providing accurate income and household information to the best of my knowledge.

• My personal information will be kept private and secure and used only for the purposes outlined in this consent.

• I am not required to share information beyond what is necessary for the application.

• I may revoke or modify this consent at any time by emailing [email protected], and revoking consent will not affect my eligibility for coverage.

By signing below, I confirm my understanding of and agreement to the terms outlined in this attestation.

Agent of Record: Worley Richards
NPN: 7918700
Phone Number: (602) 606-7785
Email Address: [email protected]