By signing below, I am confirming that my 2026 projected total annual household income is: For W2 employees its gross income before deductions. For 1099 Self-Employed its Adjusted Gross Income after Business deductions.

YES! I give BrighterDay Insurance Services (NPN: 19892301), Ranae Ferchert (NPN: 17490117), and her independent & captive agents and employees permission to access my Healthcare.gov and/or State-based Marketplace application and submit it for a health insurance policy for 2026.

YES! I give permission to look up my application and apply for health insurance!

AGREEMENTS – Please read the attestations below and sign if you agree.

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 2026 tax year. I MUST FILE A FEDERAL INCOME RETURN FOR THE 2026 TAX YEAR — NO EXCEPTIONS.

If I’m married at the end of 2026, 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 2026 federal income tax return.

• I’ll claim a personal exemption deduction on my 2026 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 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 2026 federal income tax return, the IRS will compare the income on my tax return with the income on my application.
If the income on my tax return is lower than the amount on my application, I may be eligible for an additional premium tax credit amount, or if my income is too low, I may not be eligible for tax credits at all.
If my income is higher, I may owe additional federal income tax.

I know that I must tell the program I’ll be enrolled in if any information I listed on this application changes.

I know I can make changes in my Marketplace account or by emailing BrighterDay Insurance Services at rferchert@brighterdayinsurance.com.

I know a change in my information could affect eligibility for members of my household.
If anyone on my 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.

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.

CONSENT AND PERMISSIONS

By signing below, I give permission to BrighterDay Insurance Solutions LLC and their independent & captive agents and employees to:

• Search for an existing Marketplace application.
• Complete an application for eligibility and enrollment in a Marketplace Qualified Health Plan or an application for government insurance affordability programs (Medicaid, CHIP, or APTC).
• Provide ongoing account maintenance and enrollment assistance as necessary.
• Respond to inquiries from the Marketplace regarding my application.
• Serve as the health insurance agent or broker for myself and my entire household, if applicable, for purposes of enrollment in a Qualified Health Plan.
• View and use confidential information, including personally identifiable information (PII), provided by me in writing, electronically, or by phone only for the purposes listed above.

This permission is granted for me, my spouse, or any other household member listed on the application in the plan we have applied for.

I understand that the agent will not use or share my PII for any purposes other than those listed above and will ensure that my PII is protected.

I understand that I do not have to share additional PII or protected health information (PHI) beyond what is required for eligibility and enrollment purposes.

I understand that my consent remains in effect until I revoke it, and I may revoke or modify it at any time by sending a dated and signed request to rferchert@brighterdayinsurance.com.

I consent to receive SMS notifications, alerts, calls, emails, ringless voicemails, AI texts/calls, and occasional marketing communication from the company. Message frequency varies. Message & data rates may apply. Text HELP to 844-968-6564 for assistance. You can reply STOP to unsubscribe at any time.

PURPOSE STATEMENT

Agents, brokers, and web-brokers assisting consumers with enrollment through Federally-facilitated or State-based Marketplaces must document the receipt of consent from a consumer or authorized representative prior to providing assistance and must document that eligibility application information has been reviewed and confirmed as accurate.

Acceptable documentation may include: recorded calls, text messages, emails, electronic documents with digital signatures, or physical documents with wet signatures.

Legal Disclosure:
This document does not have the force and effect of law and is not meant to bind the public in any way, unless specifically incorporated into a contract. It is intended only to clarify existing requirements.