By signing this form, you are providing your electronic signature expressly giving your consent to be contacted via an automatic telephone dialing system, by artificial voice and/or pre-recorded message, or by text message at the telephone number you provided above from or on behalf of Finhabits Insurance Services LLC, NPN 19472161 (“Finhabits”). Furthermore, you understand that consent is not a condition of purchase, and you may also receive a quote by contacting us via phone. Finhabits does not charge you for sending or receiving text messages; however, your carrier message and data rates may apply.
By signing this form, you are expressly giving your permission to Finhabits and Agents to serve as the health insurance agent or broker for yourself and your entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, you authorize Finhabits and Agents to view and use the confidential information you provided in writing, electronically, or by telephone only for the purposes of one or more of the following: (a) Searching for an existing Marketplace application; (b) Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums; (c ) Providing ongoing account maintenance and enrollment assistance, as necessary; or (d)
Responding to inquiries from the Marketplace regarding your Marketplace application.
You understand that Finhabits and Agents will not use or share your personally identifiable information (PII) for any purposes other than those listed above. The Agent will comply with applicable law when collecting, storing, and using your PII for the stated purposes above.
You confirm that the information you provide for entry on your Marketplace eligibility and enrollment application will be true to the best of your knowledge. You understand that you do not have to share additional personal information about myself or my health with Finhabits or Agents beyond what is required on the application for eligibility and enrollment purposes.
Authorization and Tax Attestation:
You give permission to Finhabits and Agents to go back in your Marketplace application and be listed as your agent of record if another agent goes into your application and changes the agent of record. This ensures that Finhabits will continue to have access to your policy. Open Enrollment begins Nov 1st of every year and this is when we need to re-enroll your health policy with us. You authorize us to auto-renew your insurance policy. This allows us to remain the agent of record and ensure your coverage does not lapse.
You confirm that you: (1) agree to allow the Marketplace to use your income data, including information from tax returns, for the next 5 years; (2) understand that you are not eligible for a premium tax credit if found eligible for other qualifying health coverage, such as Medicaid, CHIP, or a job-based health plan; (3) understand that if you become eligible for other qualifying health coverage, you must contact the Marketplace to end your coverage and premium tax credit; (4) understand if the income on your tax return is higher than the amount of income on your application, you may owe additional federal income tax. You acknowledge that to participate in the Affordable Care Act program, you are required to file taxes for any year in which you have been enrolled. Failure to do so may result in loss of future eligibility.
You understand that any or all of the previous consents remains in effect until you revoke them, and you may revoke or modify your consent at any time by email to support@finhabits.com. By using this form, you explicitly agree to our Privacy Policy and Terms and Conditions.
Agents: Lourdes Garcia (NPN: 19690100), Alberto Villar (NPN: 19443933)
Email:insurance@finhabits.com
Address: 310 N Mesa St, Suite 211. El Paso, TX 79901
