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This information is being provided to me as I am interested in purchasing an individual health insurance plan on the Marketplace. Based upon my income and plan choice I may qualify for an Advance Premium Tax Credit (APTC) to assist with the premium for the plan I choose. I may also qualify for cost-sharing assistance (CSA) which may reduce some of my out-of-pocket costs associated with the plan such as deductibles and copays.

I understand that I am purchasing this plan with the assistance of a licensed agent. The information provided to me is not intended to be legal or tax advice and for advice specific to this situation, I understand I should consult with an attorney or tax professional. I have opted to apply for assistance either in person, electronically or over the phone. I understand by engaging in this transaction I am providing consent for assistance and this consent remains indefinitely unless I choose to revoke such consent in the future either in writing or verbally to my agent listed below.