As the Primary Applicant listed on this Questionnaire, I hereby understand that by signing this Questionnaire I verify and/or agree that the information given is true and correct to the best of my knowledge and belief. I further understand that this questionnaire, and the information listed herein, constitutes a basic gathering of information intended for Utah Avenue Insurance and its affiliated agents to better understand my specific health benefit needs (including benefits through the Health Insurance Marketplace) and for entry in a health benefit plan application, and IS NOT an official application for a qualified health plan.
I acknowledge that all options and benefits of each health benefit package were explained to me in detail by Utah Avenue Insurance and/or its affiliated agents, including, but not limited to, the Utah Avenue Insurance agent listed in the authorization section of this form (“my Compass Agent”) regarding, but not limited to, insurance coverage, insurance carriers, and network providers. I also acknowledge that this is a Privacy Notice Statement in an attempt to collect Personal Identifiable Information (PII) that may be used for any qualified or non-qualified insurance benefits.
I also agree and acknowledge that I was shown health benefit coverage options that meet the minimum essential coverage as outlined under the Affordable Care Act, and thereby indemnify and hold Utah Avenue Insurance and/or my Utah Avenue Insurance Agent harmless from any liability relating to the health benefit package I choose to enroll in and for the benefits ultimately received from such health benefit package.
I further acknowledge that if I choose a non-qualified benefit package, such as, but not limited to, a short-term medical plan or limited benefit or discount plan, I understand that it does not meet the minimum essential coverage as outlined under the Affordable Care Act. I also understand that if I select a non-qualified benefit package that does not meet the minimum essential coverage as outlined under the Affordable Care Act, the resulting consequence can include, but is not limited to, any and all tax sharing, tax shared responsibility, tax penalty or any otherwise incurred penalties as carried out by the IRS relating to the Affordable Care Act. I acknowledge that the advantages and disadvantages of selecting a non-qualified benefit package have been clearly explained to me by Utah Avenue Insurance, its affiliated agents, and/or my Utah Avenue Insurance Agent.
I hereby agree to indemnify and hold harmless Utah Avenue Insurance, its employees, agents and/or my Utah Avenue Insurance Agent from and against any and all actions, claims, lawsuits, demands, costs, expenses, liabilities and losses, including reasonable attorney’s fees (“Claims”), which may result against me by reason of any acts or omissions of Utah Avenue Insurance, its agents, employees, or my Utah Avenue Insurance Agent in connection with, but not limited to, the benefits received from my selected health benefit package, the loss and/or mishandling of information listed in this Questionnaire, and/or any tax implications known or unknown relating to the benefit package I select for enrollment. I acknowledge that in order to fully understand any and all tax implications deriving from the benefit package I select, it is my responsibility to speak with a qualified tax attorney and/or accountant.
By signing this acknowledgment, I hereby authorize Utah Avenue Insurance, its affiliated agents, and/or my Utah Avenue Insurance Agent to enter any and/or all information contained in this Questionnaire in any and/or all applicable online application(s) of the insurance carrier(s) for the health benefit plan selected by me as an appropriate and potential health benefit option for myself as the Primary Applicant and for any applicable Spouse Applicant and/or Dependent Applicant(s) for all benefits included in this enrollment; this also includes entering information on healthcare.gov for purposes of, but not limited to, creating an account on my behalf and on behalf of any Spouse Applicant and/or Dependant Applicant(s) listed by me as the Primary Applicant in this Questionnaire.
Further, by signing this Questionnaire, I unreservedly authorize my Utah Avenue Insurance Agent, and/or any other Utah Avenue Insurance agent and/or employee (“Employee”), full and complete access to the information entered and/or disclosed on this Questionnaire. This authorization includes, but is not limited to, the ability for any Utah Avenue Insurance Employee to utilize this information and enter such information onto any websites requiring such information for health benefit application, enrollment and/or benefit information purposes. I further authorize my Utah Avenue Insurance Agent to electronically sign any such online health benefit application(s) on my behalf and agree that such electronic signature possess the same legal significance as if I personally and/or electronically signed the application myself.