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Name: builder-form —

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                <div class="flex email-input"><input placeholder="Email" name="email" type="email" class="form-control" data-q="email" data-required="true"><!----></div><!----><!---->
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                  style="font-family:Poppins;margin-left:10px;" for="terms_and_conditions_ep0xddb03t"><span style="color: #000000;">
                    <p>I agree to the <a style="color: #188bf6; text-decoration: none;" target="_blank" rel="noopener noreferrer nofollow" href="https://kbisolutionsllc.com/privacy-policy-terms-of-use/">terms and conditions</a> provided by the
                      company. By providing my phone number, I agree to receive text messages from the business.</p>
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          <div class="f-odd form-field-container" data-v-92ea5fef=""><!---->
            <div class="form-builder--item form-builder--item-input" data-v-92ea5fef=""><!----><label>By signing below, I am confirming that my projected income is: <!----></label>
              <div class="input-group">
                <div class="input-group-prepend"><span class="input-group-text">$</span></div><input placeholder="Projected Income" name="r7cmSHZIQoUZCeXP0wOv" type="text" class="form-control" data-q="projected_income" data-required="false">
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          <div class="f-even form-field-container" data-v-92ea5fef=""><!---->
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                <div>
                  <p style="text-align: justify"><strong>Consent</strong></p>
                  <p style="text-align: justify"><strong>I understand </strong>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. I also understand that if I become eligible for other qualifying health coverage, I must contact Kannonball Insurance Solutions LLC and/ 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 thatbecause the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or
                    my dependents:</p>
                  <p style="text-align: justify">1. I must file a FEDERAL income tax return for the 2024 tax year.</p>
                  <p style="text-align: justify">2. If I'm married at the end of 2024, I must file a joint income tax return with my spouse.</p>
                  <p style="text-align: justify">3. I must report any income changes throughout the year to prevent any issues with taxes.</p>
                  <p style="text-align: justify"><strong>I also expect that:</strong></p>
                  <p style="text-align: justify">1. No one else will be able to claim me as a dependent on their 2024 Federal income tax return.</p>
                  <p style="text-align: justify">2. I’ll claim a personal exemption deduction on my 2024 Federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and
                    who's premium for coverage is paid in whole or in part by advance payments of the premium tax credit.</p>
                  <p style="text-align: justify"><strong>If any of the above changes:</strong></p>
                  <p style="text-align: justify">1. I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2024 Federal Income tax return, the Internal Revenue Service (IRS) will compare the
                    income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may become eligible to get additional premium tax credit amount.
                    On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.</p>
                  <p style="text-align: justify">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.</p>
                  <p style="text-align: justify"></p>
                  <p style="text-align: justify"><strong>By signing below, I give permission to Kannonball Insurance Solutions LLC agents and employees to:</strong></p>
                  <p style="text-align: justify">• Search for an existing Marketplace application.</p>
                  <p style="text-align: justify">• Complete enrollment which includes submitting a 2024 application to the marketplace.</p>
                  <p style="text-align: justify">• Provide ongoing account maintenance and enrollment assistance, as necessary; or</p>
                  <p style="text-align: justify">• Respond to inquiries from the Marketplace regarding my application.</p>
                  <p style="text-align: justify">This permission is granted for me, my spouse or any other household member listed on the application in the plan that we have applied for.</p>
                  <p style="text-align: justify"><br><strong>I understand</strong> that the Agent will not use or share my personally identifiable information 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.</p>
                  <p style="text-align: justify"><strong>I understand</strong> that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any&nbsp;time by sending a written request to revoke consent to
                    <a target="_blank" rel="noopener noreferrer nofollow" href="mailto:kbisolutionsllc@gmail.com">kbisolutionsllc@gmail.com</a> that must be dated and signed.</p>
                  <p style="text-align: justify">Purpose Statement: Registered agents and brokers assisting consumers apply for and enroll in Marketplace coverage must document consumer consent prior to accessing or updating their Marketplace
                    information. CMS does not prescribe the manner in which agents and brokers must document consent. Instead, there are different formats that may be acceptable for agents and brokers to use to document consumer consent, such as via
                    a recorded phone call, text message, email, electronic document with digital signatures, physical document with wet signatures, etc. This model consent form services as an example for how agents and brokers may document consent
                    via a physical document with wet signatures.</p>
                  <p style="text-align: justify"></p>
                  <p style="text-align: justify"><strong>You may use your finger to sign below</strong></p>
                  <p style="text-align: justify"></p>
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          <div class="f-odd form-field-container" data-v-92ea5fef=""><!---->
            <div class="form-builder--item" data-v-92ea5fef=""><!----><label>By signing below I have read and agree to the text above. I also agree to the privacy policy that is linked above <span>*</span></label>
              <section class="signature-container"><span></span><a aria-label="Clear" class="clear-button">Clear</a></section><!----><!----><!---->
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</form>

Text Content

THE EXTENDED FEDERAL HEALTH PROGRAM FOR AMERICAN INDIANS AND ALASKA NATIVES


APPLY FOR EXTENDED HEALTH COVERAGE IN LESS THAN 1 MINUTE



"EMBRACE THE FREEDOM OF HEALTHCARE,


WHEREVER YOUR JOURNEY


TAKES YOU ON TRIBAL LANDS OR ACROSS THE NATION!"




YOUR QUALITY OF HEALTH IS IMPORTANT!




ACA AND YOU



Get Ready for Health Care in 2024

The Affordable Care Act, also known as the health care law, was created to
expand access to affordable health care coverage to all Americans, lower costs
and improve quality and care coordination.

If you have access to IHS health care benefits, you can continue to get your
care from IHS, tribal, or urban Indian health programs (I/T/U). These services
will always be available to you and ACA coverage will give you access to
coverage outside of IHS.



ZERO Monthly Premium ✓

ZERO Deductible✓

ZERO Out of Pocket ✓


PENDING ELIGIBILITY VERIFICATION

First Name *

Last Name *

Phone *

Email *



I agree to the terms and conditions provided by the company. By providing my
phone number, I agree to receive text messages from the business.


Who referred you? (If no one please ignore this form field)

By signing below, I am confirming that my projected income is:
$


Consent

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. I also understand that if
I become eligible for other qualifying health coverage, I must contact
Kannonball Insurance Solutions LLC and/ 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 thatbecause
the premium tax credit will be paid on my behalf to reduce the cost of health
coverage for myself and/or my dependents:

1. I must file a FEDERAL income tax return for the 2024 tax year.

2. If I'm married at the end of 2024, I must file a joint income tax return with
my spouse.

3. I must report any income changes throughout the year to prevent any issues
with taxes.

I also expect that:

1. No one else will be able to claim me as a dependent on their 2024 Federal
income tax return.

2. I’ll claim a personal exemption deduction on my 2024 Federal income tax
return for any individual listed on this application as my dependent who is
enrolled in coverage through this Marketplace, and who's premium for coverage is
paid in whole or in part by advance payments of the premium tax credit.

If any of the above changes:

1. I understand that it may impact my ability to get the premium tax credit. I
also understand that when I file my 2024 Federal Income tax return, the Internal
Revenue Service (IRS) will compare the income on my tax return with the income
on my application. I understand that if the income on my tax return is lower
than the amount of income on my application, I may become eligible to get
additional premium tax credit amount. On the other hand, if the income on my tax
return is higher than the amount of income on my application, I may owe
additional federal income tax.

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.



By signing below, I give permission to Kannonball Insurance Solutions LLC agents
and employees to:

• Search for an existing Marketplace application.

• Complete enrollment which includes submitting a 2024 application to the
marketplace.

• Provide ongoing account maintenance and enrollment assistance, as necessary;
or

• Respond to inquiries from the Marketplace regarding my application.

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


I understand that the Agent will not use or share my personally identifiable
information 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 understand that my consent remains in effect until I revoke it, and I may
revoke or modify my consent at any time by sending a written request to revoke
consent to kbisolutionsllc@gmail.com that must be dated and signed.

Purpose Statement: Registered agents and brokers assisting consumers apply for
and enroll in Marketplace coverage must document consumer consent prior to
accessing or updating their Marketplace information. CMS does not prescribe the
manner in which agents and brokers must document consent. Instead, there are
different formats that may be acceptable for agents and brokers to use to
document consumer consent, such as via a recorded phone call, text message,
email, electronic document with digital signatures, physical document with wet
signatures, etc. This model consent form services as an example for how agents
and brokers may document consent via a physical document with wet signatures.



You may use your finger to sign below



By signing below I have read and agree to the text above. I also agree to the
privacy policy that is linked above *
Clear

NEXT

CALL NOW





FREQUENTLY ASKED QUESTIONS

DO I HAVE TO SPEAK WITH AN AGENT TO COMPLETE THE APPLICATION?

Speaking with an agent is not required, if the agent does have a question of
concern they will reach out directly. The application you complete on this
website will allow them to process your coverage with your enrollment
permission.

CAN I HAVE BOTH IHS AND ACA COVERAGE AT THE SAME TIME?

Yes, you can have both Indian Health Service (IHS) coverage and Affordable Care
Act (ACA) coverage at the same time. The ACA provides options for American
Indians and Alaska Natives to continue using IHS, tribal, or urban Indian health
programs while also enrolling in a qualified health plan through the
Marketplace. This dual coverage can help ensure comprehensive health services
and coverage. You can benefit from the no-cost services provided by IHS and also
have the broader coverage that ACA plans offer, which may cover additional
services that are not available through IHS facilities (Indian Health Service) .

WHAT ARE THE SPECIAL ENROLLMENT PERIODS FOR AMERICAN INDIANS AND ALASKA NATIVES?

Members of federally-recognized tribes are allowed to purchase and enroll in
Marketplace health insurance coverage monthly rather than just during the yearly
open enrollment period. If you aren't a member of a federally recognized tribe
and don't qualify for any other special enrollment period, you must enroll
during the yearly open enrollment period.

 WHAT IS THE APPLICATION PROCESS FOR AMERICAN INDIANS AND ALASKA NATIVES?

The Marketplace offers a streamlined application process to help American Indian
and Alaska Native patients understand what benefits are available and which
protections may apply. Certain protections apply to enrolled members of
federally-recognized tribes and Alaska Native Claims Settlement Act (ANCSA)
Corporation shareholders only. In order to determine if you qualify for the
protections, you may be asked to provide additional documentation for tribal
membership and household income. By filling out one simple, user-friendly
application, you will learn if you qualify for financial assistance through
either: Advanced Premium Tax Credits to purchase coverage in the Marketplace,
Reductions in cost-sharing that will reduce or eliminate out-of-pocket costs
when you receive services using the coverage you purchased through the Health
Insurance Marketplace, or Enrollment in CHIP or Medicaid.

WHO IS KANNONBALL INSURANCE SOLUTIONS?

Kannonball Insurance Solutions is a trust enrollment partner that will process
your enrollment and help make sure you you have the best available coverage
outside of you IHS healthcare Benefits.



Copyright© 2024. All Rights Reserved .