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Affordable Health Insurance Should be Accessible to Everybody

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How It Works

Eligibility for a complimentary health plan is based on household income.

If your income falls within the blue bracket, you qualify.

Don’t wait, submit your application today!

Family Size	100%	150%	200%	400%
1	$14,580	$21,870	$29,160	$58,320
2	$19,720	$29,580	$39,440	$78,880
3	$24,860	$37,290	$49,720	$99,440
4	$30,000	$45,000	$60,000	$120,000
5	$35,140	$52,710	$70,280	$140,560

Note: Exact income levels may vary by state.

See If You Qualify:

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

YesNo

Are you currently employed? *

YesNo

Name of Your Employer *

Gender *

MaleFemale

First Name *

Last Name *

Street Address *

City

State/Province

ZIP / Postal Code

Phone *

Email Address *

Social Security Number *

Main Applicant Date of Birth *

Day *

Month *

Year *

How many people need coverage?

2nd person Name

Date of Birth

Day

Month

Year

3rd person Name

Date of Birth

Day

Month

Year

4th Person Name

Date of Birth

Day

Month

Year

5th Person Name

Date of Birth

Day

Month

Year

6th Person Name

Date of Birth

Day

Month

Year

7th Person Name

Date of Birth

Day

Month

Year

8th Person Name

Date of Birth

Day

Month

Year

9th Person Name

Date of Birth

Day

Month

Year

10th Person Name

Date of Birth

Day

Month

Year

Expected Income Per Month *

Please Be Accurate – Income will be Verified by ACA At Year End

Do you authorize us to submit your Major Medical application to the Marketplace?Do you give us permission to update your policy throughout the year if needed?

Marketplace Consent

Do we have your permission to automatically re-enroll you in your plan in the future or automatically enroll you in a similar plan if your plan does not renew in the future so you won’t lose coverage?

Please read the attestations below and sign if you agree. ACA Health Markets is owned and operated by Safe Harbor Insurance LLC.  National producer number 8199367.  State of California number 4099233.  I agree to have my information used and retrieved from government data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from government data sources. I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for 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 Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. I also 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 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 2024 tax year. I MUST FILE A FEDERAL INCOME RETURN FOR THE 2023 TAX YEAR. If I’m 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. I’ll 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 this Marketplace, and whose 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. PLEASE READ ATTESTATIONS BELOW BEFORE YOU SIGN AND SUBMIT YOUR APPLICATION: 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 contacting Safe Harbor Insurance LL  Call  480-800-4809. 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. You consent to the use of an electronic signature to sign all forms presented to you by Safe Harbor Insurance LLC during the health insurance policy application process, unless and until you withdraw your consent to the use of electronic signatures by providing notice to the address below, and agree that this consent is effective on the date that you affix your signature below. By signing below, you agree to be legally bound as if you had signed this form and other documents with a handwritten signature, and you acknowledge that you have reviewed and agree to the above terms and conditions. If you have any questions, please contact us at support@safeharborinsuranceagency.com  Please signify your agreement with the foregoing by signing below. 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. You consent to the use of an electronic signature to sign all forms presented to you by Safe Harbor Insurance LLC during the health insurance policy application process, unless and until you withdraw your consent to the use of electronic signatures by providing notice to the address below, and agree that this consent is effective on the date that you affix your signature below. By signing below, you agree to be legally bound as if you had signed this form and other documents with a handwritten signature, and you acknowledge that you have reviewed and agree to the above terms and conditions. If you have any questions, please contact Safe Harbor Insurance LL.   support@safeharborinsuranceagency.com  Please signify your agreement with the foregoing by signing below. I hereby authorize Safe Harbor Insurance LLC to sign the application for Federally Facilitated Exchange health insurance on my behalf, and to store my electronic signature affixed below for purposes of doing so. I understand that at this time I have not yet applied for Federally Facilitated Exchange health insurance, and that Safe Harbor Insurance LLC will be using the information and consents I provide herein to fill out, sign on my behalf, and submit the Federally Facilitated Exchange application. By pressing the submit button above (1) I understand that I am using an electronic signature to express written consent to receive emails, telephone calls, text messages, artificial or pre-recorded messages from Safe Harbor Insurance. (2) I agree to this websites Privacy Policy (https://acahealthmarkets.com/) and Terms of Use (https://acahealthmarkets.com/. If you have questions about our Privacy Policy, please contact us at support@safeharborinsuranceagency.com California residents exercising their “right to know” or “right to deletion” can click to make a request online or contact us at support@safeharborinsuranceagency.com  Each request is subject to verification. California and Nevada residents exercising the right to opt out of the sale of their data should access our Do Not Sell My Info form here. For more information regarding these privacy matters, please refer to our Privacy Policy. Providing false information may subject you to liability. I understand that my consent is not required as a condition of purchase and that I may revoke my consent at any time. I understand the best communication is through text and or email. I consent to opt in for email and text messaging. I understand we may call or email you when we need to update your policy to share important information with you. I give Safe Harbor Insurance LLC my permission to with any documentations the Marketplace may require and submit your income letter on your behalf with the same details you provided us with today. You attest to allow Safe Harbor Insurance LLC to request document extensions on your behalf if you run out of time and documents are still pending. I give permission to Safe Harbor Insurance LLC, to automatically re-enroll you in your plan in the future or automatically enroll you in a similar plan if your plan does not renew in the future so you won’t lose coverage. I attest that my household income if there are any changes to income, you will notify us or the marketplace.

I have read and agree to the terms above, and I attest that the personal information I have provided is true and correct

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CONTACT
customerservice@resiliencehealthagency.com
+1 (888) 533-5102

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