ACA Health Markets is committed to protecting the privacy of the data relating to our users, and their clients. We will collect, store, use and protect any personal information that you share with us. We will not share your information with anyone, except as described in this Privacy Policy.
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 Tax 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 ACA Health Markets Agents to submit the application for enrollment and notify me of these changes via the email I provided on the application.
I authorize and consent that ACA Health Markets, Dave Evans, or one of its affiliated licensed agents will be my agent of record. I authorize them to submit and sign this application on my behalf and use 3rd party verification tools to confirm my eligibility requirements, such as date of birth, social security number, address, legal name etc, as well as update my existing marketplace application, and process my renewal applications unless I revoke this authorization. This Consent and Authorization will Remain in place unless rescinded.
You request that we will make sure we are the Agent of Record on your account each month until consent is revoked. We will also make sure your application is up to date for Open Enrollment each plan year. If your current plan is discontinued, we will enroll you in the best plan you qualify for. If your eligibility changes, you are required to let us know. This permission may be rescinded at any time by emailing
support@acahealthmarkets.com.
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 tax 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.
I agree that I have read this and and I give my permission to {{user.name}} and {{location.name}} to serve as my broker for myself and my household, for the purpose of enrollment in a qualified Health Plan offered by the Federal Facilitated Marketplace. I consent to allow the above mentioned agent to view use my confidential information for the following purposes:
1. Search for an existing Marketplace Plan;
2. Complete and application for eligibility and enrollment in a Marketplace Plan;
3. Provide ongoing maintenance and enrollment assistance; or
4. Respond to inquiries from the Marketplace regarding my application.
If your income is $0 (or less than the Federal Poverty Limit), you attest that your estimated income for 2023 will be at least the Federal Poverty Limit for your state and household requirements. If your income will be less than (or greater than) those limits, you agree to notify us or the marketplace of any changes or updates as soon as possible. Failure to notify us of any changes may result in your eligibility being affected. Job Seeking: I Agree to notify {{location.name}} if my estimated income for 2023 changes.
I confirm what I have shared is accurate and true for entry on my Marketplace Health Insurance Application, that I have read and consent with the terms and understand the above mentioned agent will safely store and use my personal identifiable information for the above stated purposes.
I understand my consent remains until I revoke it by emailing us at support@acahealthmarkets.com or support@safeharborinsuranceagency.com.
By signing or consenting to the document, I am affirming that I agree to all the above statements.
Throughout this Privacy Policy, we will refer to our website, applications delivered via the web, and other related services collectively as the “Service.”
This Privacy Policy does not apply to information we collect by other means than your use of the Service (including offline) or from other sources. When you sign up with ACA Health Markets and use the Service you agree to accept this Privacy Policy.
We reserve the right to change this policy at any time, and if we do so, we will post changes and updates to this page. Please refer to this policy periodically to inform yourself if changes have been made.
We collect certain information through our website, located at ww.acahealthmarkets.com/ (our “Website”). This page (this “Privacy Policy”) lays out our policies and procedures surrounding the collection and handling of any such information that identifies an individual user or that could be used to contact or locate him or her (“Personally Identifiable Information” or “PII”).
We collect the following Personally Identifiable Information from users who buy our products and services: name, email address, telephone number, address, and credit card number.
In addition, upon using the Service, individual transaction data obtained from your third-party invoicing or accounting application, (“Quickbooks,” “Xero,” “Clio” etc.) information collected via the browser, user generated content and other information uploaded to the website by the user, in conjunction with your use of the Service may be collected. Information obtained through these means that relates to the user’s client or customer to be invoiced through HealthSherpa may at times be referred to as “Third-Party Client Information” throughout this Privacy Policy.
Additional information from or about you may also be collected in other ways, including responses to customer surveys and any communications with our customer service team.
We use “cookies” so that our Website can remember you and provide you with the information you’re most likely to need. For instance, when you return to the Website, cookies identify you and prompt the site to provide your username (not your password), so you can sign in more quickly. Cookies also allow our Website to remind you of your past usage and to suggest similar products and services. Finally, we use information gained through cookies to compile statistical information about use of our Website, such as the time users spend at the site and the pages they visit most often. Those statistics do not include PII.
We use your Personally Identifiable Information to create your account, to communicate with you about products and services you’ve purchased, to offer additional products and services, and to bill you. We also use this information to the extent necessary to enforce our Website terms of service and to prevent imminent harm to persons or property.
When you use the Service, including accepting a payment, contacting customer service or requesting technical support, in addition to many other interactions with {{location.name}}, we will apply the information that we have collected. Knowing this information allows us to verify your identity, communicate with you and enforce our agreements with you, as well as secure the best possible experience for all {{location.name}} customers by ensuring compliance with applicable US state and federal laws and our own policies. We may also use this information to improve and enhance our offerings to you.
Safe Harbor Insurance LLC d.b.a. ACA Health Markets may use certain information about you without identifying you as an individual to third parties. We do this for purposes such as analyzing how the Service is used, diagnosing service or technical problems, maintaining security, and personalizing content.
Information that can be used to identify a person is “Personally Identifiable Information”. This does not include information that has been aggregated or made anonymous. All information is securely stored on our servers in the United States. We employ the highest in industry standards to protect Personally Identifiable Information, as well as any information provided relating to your invoiced customers.
Third-party client and customer information, provided to ACA Health Markets by users, shall be considered confidential and shall not be disclosed to any third party, unless required to do so by law or subpoena or if we believe that such action is necessary to conform to the law, or comply with legal process served on us. Such information shall be utilized only for the purpose for which {{location.name}} was created, which is to facilitate the billing and collection process for electronic billing of customers and clients.
Although Safe Harbor Insurance LLC d.b.a. ACA Health Markets utilizes the highest reasonable levels of data security in the industry, we can not guarantee the security of PII or other information provided to us. By using our Website, you acknowledge and agree that we make no such guarantee, and that you use our Website at your own risk.
Safe Harbor Insurance LLC d.b.a. ACA Health Markets will not rent or sell your Personal Information to others. We may store personal information in locations outside the direct control of {{location.name}} (for instance, on servers or databases co-located with hosting providers). Safe Harbor Insurance LLC d.b.a. ACA Health Markets will share your Personal Information with a limited number of Safe Harbor Insurance LLC d.b.a. ACA Health Markets partners for the explicit purpose of providing services to you. If we do this, such third parties’ use of your Personal Information will be bound by terms at least as restrictive as this Privacy Policy
As we develop our business, we may buy or sell assets or business offerings. Customer, transaction, email, and visitor information is generally one of the transferred business assets in these types of transactions. We may also transfer such information in the course of corporate divestitures, bankruptcy, mergers, or dissolution.
Except as otherwise described in this Privacy Policy, Safe Harbor Insurance LLC d.b.a. ACA Health Markets will not disclose Personal Information to any third party unless required to do so by law or subpoena or if we believe that such action is necessary to (a) conform to the law, comply with legal process served on us or our affiliates, or investigate, prevent, or take action regarding suspected or actual illegal activities; (b) to enforce our User Agreement, take precautions against liability, to investigate and defend ourselves against any third-party claims or allegations, to assist government enforcement agencies, or to protect the security or integrity of our site; and (c) to exercise or protect the rights, property, or personal safety of {{location.name}}, our customers or others.
In the event that personal information is compromised as a result of a breach of security, Safe Harbor Insurance LLC d.b.a. ACA Health Markets will promptly notify those persons whose personal information has been compromised, in accordance with the notification procedures set forth in this Privacy Policy, by email, or as otherwise required by applicable law.
Safe Harbor Insurance LLC d.b.a. ACA Health Markets shall not be liable for the transfer of any personal identification information resulting from loss or distribution of data, the delineation or corruption of storage media, power failures, natural phenomena, riots, acts of vandalism, sabotage, terrorism or any other event beyond {{location.name}}’s control.
You may, of course, decline to submit personally identifiable information through the Service, in which case Safe Harbor Insurance LLC d.b.a. ACA Health Markets }} may not be able to provide certain services to you. You may update or correct your account information at any time by logging in to your account. You can review and correct the information about you that {{location.name}} keeps on file by contacting us as described below.
Safe Harbor Insurance LLC d.b.a. ACA Health Markets does not knowingly collect or solicit personal information from anyone under the age of 18 or knowingly allow such persons to register with our Service. If you are under 18, please do not send any information about yourself to us, including your name, address, telephone number, or email address. No one under age 18 is allowed to provide any personal information to or on {{location.name}}. In the event that we learn that we have collected personal information from a minor under age 18 without verification of parental consent, we will delete that information as quickly as possible. If you believe that we might have any information from or about a child under 18, please contact us as described below.
Safe Harbor Insurance LLC d.b.a. ACA Health Markets is not responsible for the practices employed by websites linked to or from our website, nor the information or content contained therein. Please remember that when you use a link to go from our website to another website, our Privacy Policy is no longer in effect. Your browsing and interaction on any other website, including those that have a link on our website, is subject to that website’s own rules and policies. Please read over those rules and policies before proceeding.
It is our policy to provide notifications, whether such notifications are required by law or are for marketing or other business related purposes, to you via email notice, written or hard copy notice, or through conspicuous posting of such notice on our website, as determined by {{location.name}} in its sole discretion. We reserve the right to determine the form and means of providing notifications to you.
If we change our privacy policies and procedures, we will post those changes on our website to keep you aware of what information we collect, how we use it and under what circumstances we may disclose it. Changes to this Privacy Policy are effective when they are posted on this page.
Please contact us with any questions or concerns regarding our policy.
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CONTACT
service@acahealthmarkets.com
480-685-9560
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