Bass Insurance Solutions Survey Form

ACA Marketplace Survey Form

Personal Details

Legal FIRST and LAST Name *

Date of birth *

Address

Street Address *

City

State

Country

Zip Code

Gender *

Male

Female

Mailing Address(if different than street address)

Complete Social Security # to verify U.S citizenship *

Client Immigration Status *

Upload your Primary ID Here

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF Example: Driver's License or etc.

Upload your Secondary ID here

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF Example: Social Security Card or Etc.

Upload other image here

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Upload other image here.

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Phone # *

Email Address *

By signing below, you attest that the previously provided information constitutes the information used to create your Marketplace application and that you have reviewed this information and it is accurate *

Clear

Estimated ANNUAL Income before taxes or anything come out from all income sources. *

Enrollment Eligibility *

Source of Income *

Name of the company you work with or the type of work you do *

How many people do you claim in your taxes besides you? *

Single Person

Mutiple Person

I grant Bass Insurance Solutions, Inc and/or Melissa Bass the permission 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 Bass Insurance Solutions, Inc and/or Melissa Bass 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: 1. Searching for an existing Marketplace application; 2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid or CHIP or advance tax credits to help pay for Marketplace premiums; 3. Providing ongoing account maintenance and enrollment assistance, as necessary; or 4. 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 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. I also request that Bass Insurance Solutions, Inc automatically re-enroll me in a plan for renewal each year. *

I Agree

Do they need insurance? *

Yes

List Below anyone else who you claim on your taxes, and do they need insurance?

Only list people you claim on your taxes

Do you have Medicare, Medicaid, or insurance through your employer? *

Yes

I attest that my estimated income will be at least the Federal Poverty Limit for my state and household size. I agree to notify Bass Insurance Solutions, Inc of any expected income changes that I have listed on the application. I understand that failure to notify Bass Insurance Solutions, Inc could affect my eligibility.

Referred By:

Is the person a tobacco user?

HealthCare.gov account access

I give you permission to access me and/or my family HealthCare.gov account to enroll in a health insurance plan *

I Agree

I agree this is a request to ENROLL you in a FREE or next best available health plan. I agree if you already have a marketplace plan we may switch you to a better plan if one is available, if you are already on the best plan you are requesting the current agent currently designated on this policy to be removed and Melissa Bass to become your agent of record from this point on unless notified in writing of the change. This request can be revoked at anytime by sending a request email to customercare@bassinsurancesolutions.com *

I Agree

Please read attestation below before you sign and submit *

I have read and agree to the following Disclosures:

I attest that my estimated income for 2027 will be at least the Federal Poverty Limit for my state and household size. I agree to notify Bass Insurance Solutions Inc as soon as I become aware of any changes to the expected household income per month that I have provided above. I understand that failure to notify Bass Insurance Solutions Inc of such changes may affect my eligibility. By signing below, I hereby provide consent and authorize Bass Insurance Solutions, Inc to enroll me and any other individuals I identified above in an ACA Plan available through the Federally Facilitated Exchange (the “Marketplace”). If I already have health insurance, I request that Bass Insurance Solutions, Inc and its agents become my agent of record or switch me to a better plan if one is available. This consent will remain in effect unless and until rescinded by you in writing. This consent can be rescinded at any time by sending an email to customercare@bassinsurancesolutions.com Additionally, by signing below I attest to the fact that I have reviewed the information I have provided above and that it is accurate and complete in all material respects. I grant Bass Insurance Solutions, Inc and/or Melissa Bass the permission to 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 Bass Insurance Solutions, Inc and/or Melissa Bass 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: 1. Searching for an existing Marketplace application; 2. 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; 3. Providing ongoing account maintenance and enrollment assistance, as necessary; or 4. 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. I also request that Bass Insurance Solutions, Inc automatically re-enroll me in a plan for renewal each year. Bass Insurance Solutions, Inc will maintain this form or a true and correct copy of this form in its records. You may want to make a copy of this form for your records. I have read Bass Insurance Solutions, Inc website privacy policies, which can be found here - https://applyforfreehealthinsurance.com/privacy-policy/ Eligibility I understand that I’m required to provide true and complete answers to the questions posed above and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If the information provided by me is not true and complete I may face penalties, including the risk of losing my eligibility for coverage. I understand that if anyone I identified above as needing coverage is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. 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 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 Medicare, Medicaid, the Children’s Health Insurance Program (“CHIP”), or a job-based health plan. I also I 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 the foregoing does not constitute tax advice provided by Bass Insurance Solutions Inc to me, and that should I have any questions regarding any tax credits for which I may be eligible, my tax returns, or any other related tax matters I should consult a qualified tax advisor prior to enrolling in health insurance coverage provided via the Marketplace. Electronic Signature and Communications I consent to receive all notices electronically and to the use of an electronic signature to sign all forms presented to me by Bass Insurance Solutions, Inc during the health insurance enrollment process, including, without limitation, privacy policies, consent forms, and to sign this form below, unless and until I withdraw my consent to the use of electronic signatures by providing notice to customercare@bassinsurancesolutions.com, in which case we will provide paper copies. I also understand that my consent remains in effect until I choose to revoke it, and I retain the right to revoke or notify my consent at any time by sending an email, text, or making a phone call to the following: Name of Primary Writing Agent: Melissa Bass Agent National Producer Number: 18806223 Phone Number: (803) 918-5306 Email Address: customercare@bassinsurancesolutions.com. I agree that this consent is effective on the date that I affix my signature below. 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 2027 tax year. If I’m married at the end of 2027, 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 2027 federal income tax return. I’ll claim a personal exemption deduction on my 2027 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. I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2027 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 if information I listed on this application changes. I know I can make changes in my Marketplace account or by texting Bass Insurance Solutions, Inc at 803-918-5306. 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 later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost. I understand that at this time I have not yet applied for health insurance, and that Bass Insurance Solutions, Inc. will be using the information and consents I provide herein to fill out, sign, and submit the Marketplace application on my behalf, and take any other actions pursuant to the authority I delegated to Bass Insurance Solutions, Inc which are deemed necessary or appropriate by Bass Insurance Solutions, Inc to obtain coverage on my behalf. I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information

Clear

Time of Signature

Date of Signature *

Consent to Contact & Warm Handoff Acknowledgment *

I agree

By completing this survey, I understand this is not an application for insurance coverage. I give permission for Bass Insurance Solutions and its licensed agents to contact me by phone, email, or text message to discuss my eligibility and available health plan options. If I choose, a licensed agent may be contacted immediately while I am present to continue this process.