Please select an option based on carrier and state:
Constantine Christoforakis, 17328248 = Everything EXCEPT for BCBSFL, Florida Healthcare Plans (FHCP), & Vantage LA
Francis Naimoli, 17415842 = ONLY BCBS FL & Florida Healthcare Plans (FHCP))
Mark MacFawn, 8997756 = ONLY Vantage LA
1. No one applying for coverage is in jail.
2. I give permission to the federal marketplace to access my tax returns years for up to five years to verify my income for subsidy purposes. I can revoke this permission at anytime.
3. I will notify the insurer if anything on this application changes. I can do this through the federal marketplace. I understand a change could affect our eligibility for plans and subsidies.
4. I’m electronically signing this application, which means I’ve provided true answers to all of the questions to the best of my knowledge.
5. I authorize (Your Name) to submit and sign this application on my behalf.