Brandon Smotherman Insurance

For Affordable Care Act enrollments:

I certify that the information provided is true and accurate

I attest that no one applying for health coverage on this application is incarcerated.

I attest that no member on the enrollment application has group coverage offered to them.

I give permission to the marketplace to access my . returns for up to 5 years to verify my income for subsidy purposes. This permission can be revoked at any time. However, if I revoke permission, I understand that I will be required to complete a federal application every year to confirm my income and subsidy eligibility. I understand that should the information listed on this application for enrollment change, it is my responsibility to update the information with the federal marketplace. I understand that I can make changes by accessing my marketplace account online or by calling 1-800-318-2596. I further understand that a change in my information could affect eligibility for members of my household.

I agree to allow HealthSherpa to submit my healthcare.gov financial assistance and health insurance application on my behalf. I understand that changes may occur to my premium based on my subsidy eligibility results. Further, I authorize HealthSherpa and BP Marketing Agents to submit the application for enrollment and notify me of these changes via the email I provided on the application.

I acknowledge Brandon Smotherman ACA or its Agency affiliates, as my agent of record and authorize them to submit and sign this application on my behalf. 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 in 2024 for the tax year of 2023.

• If I'm married at the end of 2023, 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 2023 federal income tax return.

• I'll claim a personal exemption deduction on my 2023 federal income . return for any individual listed on this application as a dependent who is enrolled in coverage through this marketplace and whose premium for coverage is paid in whole or in part by advance payments.

• If any of the above changes, I understand that it may impact my ability to get a premium tax credit.

I also understand that:

• When I file my 2023 federal income tax return, the Internal Revenue Service (IRS) will compare the income on tax return with the income on my application.

• 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.

• If the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

By signing or clicking yes on the ad, I am affirming that I agree to all the above statements.

1. Terms

By accessing this web site, you are agreeing to be bound by these

web site Terms and Conditions of Use, all applicable laws and regulations,

and agree that you are responsible for compliance with any applicable local

laws. If you do not agree with any of these terms, you are prohibited from

using or accessing this site. The materials contained in this web site are

protected by applicable copyright and trade mark law.

2. Use License

Permission is granted to temporarily download one copy of the materials

(information or software) on Life Benefits Insurance’s web site for personal,

non-commercial transitory viewing only. This is the grant of a license,

not a transfer of title, and under this license you may not:

• modify or copy the materials;

• use the materials for any commercial purpose, or for any public display (commercial or non-commercial);

• attempt to decompile or reverse engineer any software contained on Life Benefits Insurance’s web site;

• remove any copyright or other proprietary notations from the materials; or

transfer the materials to another person or “mirror” the materials on any other server.

This license shall automatically terminate if you violate any of these restrictions and may be terminated by Life Benefits Insurance at any time. Upon terminating your viewing of these materials or upon the termination of this license, you must destroy any downloaded materials in your possession whether in electronic or printed format.

3. Disclaimer

The materials on Life Benefits Insurance’s web site are provided “as is”. Life Benefits Insurance makes no warranties, expressed or implied, and hereby disclaims and negates all other warranties, including without limitation, implied warranties or conditions of merchantability, fitness for a particular purpose, or non-infringement of intellectual property or other violation of rights. Further, Life Benefits Insurance does not warrant or make any representations concerning the accuracy, likely results, or reliability of the use of the materials on its Internet web site or otherwise relating to such materials or on any sites linked to this site.

4. Limitations

In no event shall Life Benefits Insurance or its suppliers be liable for any damages (including, without limitation, damages for loss of data or profit, or due to business interruption,) arising out of the use or inability to use the materials on Life Benefits Insurance’s Internet site, even if Life Benefits Insurance or a Life Benefits Insurance authorized representative has been notified orally or in writing of the possibility of such damage. Because some jurisdictions do not allow limitations on implied warranties, or limitations of liability for consequential or incidental damages, these limitations may not apply to you.

5. Revisions and Errata

The materials appearing on Life Benefits Insurance’s web site could include technical, typographical, or photographic errors. Life Benefits Insurance does not warrant that any of the materials on its web site are accurate, complete, or current. Life Benefits Insurance may make changes to the materials contained on its web site at any time without notice. Life Benefits Insurance does not, however, make any commitment to update the materials.

6. Links

Life Benefits Insurance has not reviewed all of the sites linked to its Internet web site and is not responsible for the contents of any such linked site. The inclusion of any link does not imply endorsement by Life Benefits Insurance of the site. Use of any such linked web site is at the user’s own risk.

7. Site Terms of Use Modifications

Life Benefits Insurance may revise these terms of use for its web site at any time without notice. By using this web site you are agreeing to be bound by the then current version of these Terms and Conditions of Use.

8. Governing Law

Any claim relating to Life Benefits Insurance’s web site shall be governed by the laws of the United States of America without regard to its conflict of law provisions.

General Terms and Conditions applicable to Use of a Web Site.