2027 Health Insurance Questionnaire with ACA Health Insurance Marketplace

10. Your income estimate matters. Your tax credit (APTC) is based on the income we put on your application. When you file your 2027 taxes, the IRS compares your actual income to that estimate.

• If your actual income is higher than your estimate, you may have to pay back some or all of the tax credit you received. Starting with the 2026 tax year, there is no longer a limit on how much you may have to pay back.
• If your income goes over 400% of the Federal Poverty Level for your household size, you will not qualify for any tax credit for 2027 and will have to pay back all of it. For example, a household of 5 that makes over $154,720 would have to pay back every dollar. If you receive $1,500 per month in tax credits, that would be $1,500 for EACH month you had this insurance.
• If your income changes during the year, let us know right away so we can update your application.

Federal Poverty Guidelines & 2027 Income Thresholds

The Marketplace uses the prior year's federal poverty guideline for a coverage year. Figures are for the 48 contiguous states and the District of Columbia; Alaska and Hawaii have higher guidelines. 2027 income thresholds are calculated from the 2026 guideline. In Medicaid-expansion states, adults under 138% FPL generally go to Medicaid.

15. Do you want to keep the most similar plan offered in 2027 to the one you have now? Plans and prices change every year, so expect some changes. What we want to know is whether you are happy with your plan and want to keep the most similar one available.

20. If we can ever help you with any of our other insurance services, just let us know. We offer health insurance, dental insurance, vision insurance, life insurance, home insurance, auto insurance, Medicare, and Group benefits (for companies).

I certify that the information in this questionnaire is true and correct as of the date I submit it to Peine Insurance, and that it is accurate for completing my 2027 application for insurance enrollment.

• I release Peine Insurance, and each of its employees, agents, contractors, representatives, assigns and heirs (collectively "PEINE INSURANCE") from any and all liability related to the completion and submission of my health insurance application, based on the information I provide, as well as any other insurance products that I purchase with PEINE INSURANCE.
• I authorize PEINE INSURANCE to fill out and submit my Marketplace health insurance application on my behalf through healthcare.gov or HealthSherpa, after I have reviewed and confirmed the information in it.
• I will have the chance to review my health insurance application before it is submitted, and I take full responsibility for the information I give PEINE INSURANCE to complete it.
• I understand that the answers on my Marketplace application are my responsibility. I release PEINE INSURANCE from liability related to Healthcare.gov, the IRS, or the Federally Facilitated Marketplace that results from the information I provided and confirmed.
• I give consent to PEINE INSURANCE and its affiliated agents to log into my application on healthcare.gov or through HealthSherpa to complete, maintain, and update my enrollment. I understand that PEINE INSURANCE relies on the information I provide to complete the application.
• I understand that I must file a federal income tax return to receive the APTC (Advance Premium Tax Credit), and that the return must include everyone in my tax household (ALL DEPENDENTS). I take full responsibility for any taxes or repayments associated with my tax return, and I release PEINE INSURANCE from liability related to the APTC.
• I understand that if my income is higher than estimated, or goes over 400% of the Federal Poverty Level, I may have to pay back some or all of the Advance Premium Tax Credits I received. I release PEINE INSURANCE from any and all liability relating to the repayment of Advance Premium Tax Credits to the IRS.

2027 Advance Premium Tax Credit Disclosure

• I understand that I'm not eligible for a premium tax credit if I'm found eligible for other qualifying health coverage, like Medicaid, Children's Health Insurance Program (CHIP), or a job-based health plan. 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 I will lose my premium tax credit if I'm found eligible for other minimum essential coverage, like coverage through my job or Medicare.
• 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 tax year 2027.
  • If I'm married at the end of 2027, I must file a joint income tax return with my spouse.
  • No one else will be able to claim me as a dependent on their 2027 federal income tax return.
  • I will claim as a dependent on my 2027 federal income tax return anyone listed on this application as my dependent who is enrolled in Marketplace coverage paid in whole or in part by advance payments.
• I know that I must tell the Marketplace within 30 days if information I listed on my application changes. I can make changes in my Marketplace account, through my agent, or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
• If anyone on my application is enrolled in Marketplace coverage and is also found to have Medicare coverage, the Marketplace will automatically end their Marketplace plan coverage after sending a notice. During any months of overlapping coverage, they are responsible for the full cost of the Marketplace plan premium and covered services. I agree to allow the Marketplace to end coverage in this situation.
• If anyone on this application enrolls in Medicaid, I'm giving the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I'm also giving the Medicaid agency rights to pursue and get medical support from a spouse or parent.

• Disputes. If there is any dispute, claim, or disagreement related to this agreement or to services provided by PEINE INSURANCE ("Dispute"), we agree to first contact each other in writing and try in good faith to resolve it informally within 30 days. If it is not resolved, we agree to try mediation before a neutral mediator. If mediation does not resolve the Dispute within 60 days, it will be settled by final and binding arbitration administered by the American Arbitration Association (AAA) under its Consumer Arbitration Rules, and judgment on the award may be entered in any court with jurisdiction. The arbitration will take place in the county where I live or by video or phone, and fees will be paid as provided by the AAA Consumer Arbitration Rules. Either party may bring an individual claim in small claims court instead of arbitration if it qualifies. Disputes will be resolved only on an individual basis, and not as part of any class, collective, or representative action. This section is governed by the Federal Arbitration Act.
• PEINE INSURANCE does not give immigration or legal advice. If I have questions about how health coverage or tax credits could affect my immigration status, I will talk with an immigration attorney.
• If I am on an F1, F2, J1, J2 or any other visa, I understand that I must file a tax return and that I am responsible for any taxes or repayments I owe the IRS.
• I understand that if I am offered or have health insurance through an employer at any time, even if I choose not to enroll in it, I may not qualify for the premium tax credit and may have to pay it back. I take full responsibility for reporting this to the Marketplace and for reconciliation with the IRS.
• If PEINE INSURANCE fills out and submits the application on my behalf, as I have authorized, I understand that the answers are based on what I told them and what I reviewed. If I or any of my family members were denied Medicaid or CHIP, I authorize PEINE INSURANCE to report that as part of the application.
• It is my responsibility to cancel my policy when I am ready to. I can cancel by calling the Health Insurance Marketplace at 1-800-318-2596 or by asking my agent for help. I release Peine Insurance from liability related to the cancellation of my policy.
• I have had the chance to read this agreement and ask questions, and I agree to be bound by its terms.
• This agreement stays in effect unless either party ends it in writing.
• This agreement may be signed electronically, and electronic signatures have the same force and effect as handwritten signatures.
• I have the capacity to enter into this Agreement and I am not under duress or undue influence.
• This is the entire agreement. Any prior verbal or written understandings between the parties are replaced by this Agreement.

• To make it easier to determine my eligibility for help paying for coverage in future years, I consent to the Marketplace using my income information, including data from my tax returns, for the next five years. I can opt out at any time.
• I agree to allow the Marketplace to end the Marketplace coverage of anyone on my application who is enrolled in Marketplace coverage and is later found to have other qualifying health coverage, such as Medicare, Medicaid, or CHIP. This keeps them from staying enrolled and having to pay the full cost.
• If any of my application details change, I understand it may affect my premium tax credit. When I file my federal income tax return, the IRS will compare the income on my tax return with the income on my application. If my income is lower, I may get an additional premium tax credit. If it is higher, I may need to repay some or all of the advance payments of the premium tax credit.
• 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. I know I may be subject to penalties under federal law if I intentionally provide false information.

I affirm that the information I provided to my Broker is true, accurate, and complete to the best of my knowledge and belief.

As the Primary Applicant listed on this Questionnaire, I verify that the information given is true and correct to the best of my knowledge and belief. I understand that this Questionnaire gathers basic information for Peine Insurance and its affiliated agents (collectively "PEINE INSURANCE") to understand my health benefit needs (including benefits through the Health Insurance Marketplace) and to enter into a health benefit plan application. It IS NOT an official application for a qualified health plan.

I acknowledge that the options and benefits of each health benefit package were explained to me by PEINE INSURANCE, including my Peine Insurance Agent listed in the Enrollment Consent section of this form, including insurance coverage, insurance carriers, and network providers. I understand this form collects personally identifiable information (PII) that will be used only to help me get and keep insurance coverage, as described in the Enrollment Consent below.

I acknowledge that I was shown health benefit coverage options that meet the minimum essential coverage requirements of the Affordable Care Act, and that the choice of plan is mine.

If I choose a non-qualified benefit package, such as a short-term medical plan or limited benefit or discount plan, I understand that it does not meet the minimum essential coverage requirements of the Affordable Care Act and may result in tax consequences. The advantages and disadvantages of a non-qualified benefit package have been explained to me by PEINE INSURANCE.

I agree to hold PEINE INSURANCE harmless from claims, costs, and losses that result from information I provided that was inaccurate or incomplete, or from tax consequences of the benefit package I choose. To fully understand any tax implications, it is my responsibility to speak with a qualified tax professional.

I authorize PEINE INSURANCE and/or my Peine Insurance Agent to enter the information in this Questionnaire into the online application(s) for the health benefit plan I select, for myself and for any Spouse or Dependent Applicants listed, including on healthcare.gov and HealthSherpa. This includes creating or accessing an account on my behalf. I will review the application before it is submitted and confirm that it is true and accurate.

I authorize my Peine Insurance Agent and PEINE INSURANCE staff to access and use the information in this Questionnaire to complete my application, enrollment, and ongoing account maintenance, and to submit my application electronically on my behalf after I have reviewed and approved it.

I, the primary household contact named below, give my permission to the Agent named below ("Agent") to 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 offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the Agent to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following:

• Searching for an existing Marketplace application
• 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
• Providing ongoing account maintenance and enrollment assistance, as necessary
• Responding to inquiries from the Marketplace regarding my application

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

• I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge.

I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my Agent.

By signing below, I confirm that the information in this form is true and correct, and I agree to everything in this form: the Terms & Conditions, the Advance Premium Tax Credit Disclosure, the Application Attestations, the Terms, Conditions, and Disclosure of Information, and this Enrollment Consent. My electronic signature is just as valid as a handwritten signature.