Quote Request for Private Health Insurance

Step 1 of 3

Requested Effective Date
MM slash DD slash YYYY
Policyholder Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
Tobacco Use*
Address*
Street Address County City State ZIP Code
Phone*
Email*
Spouse and/or Dependent Information
Use the + icon at the end of each row to add additional rows as needed
First Name Last Name Date of Birth Gender Tobacco Use

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Current Coverage
Have you recently lost Medicaid coverage?*
- Yes
- No
Date Medicaid coverage was lost
MM slash DD slash YYYY
Name of your current health insurance company*
Do you currently receive a subsidy through the Marketplace to help cover the cost of your insurance?*
- Yes
- No
Are you, or anyone listed on this form, offered health insurance from their employer?*
Income Information
You may be eligible for a subsidy/premium tax credit to help pay your healthcare premium. To determine if you are eligible please provide us with your estimated total household income for 2023.
Estimated 2023 household income*

Privacy Notice Statement Pertaining to Personally Identifiable Information
I acknowledge and agree that:*
I have read the Privacy Notice Statement Pertaining to Personally Identifiable Information and I hereby authorize KHI Solutions to collect and use my PII to the extent reasonably necessary to assist in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHP’s through the Marketplace, and/or applying for Federal subsidies, and any other health related plan.
This Privacy Notice Statement explains how KHI Solutions (also referred to as “we” or “us) may collect, use and disclose certain personally identifiable information (also referred to as “PII) in the course of assisting customers in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in a qualified health plan (also referred to as “QHP’s”) through the Federally Facilitated Marketplace (“FFM” or “Marketplace”) or direct though the insurance carrier, and/or applying for Federal subsidies.

PII includes any information that can be used to distinguish or trace your identity, either alone or in combination with other personal or identifying information that is linked to you.

Examples of PII include:
-Name, address
-Phone number
-Social Security Number
-Date/place of birth
-Mother’s maiden name

This Statement describes, in particular:
1)The legal authority for KHI Solutions to collect PII
2)The purpose of our collection of PII
3)To whom and for what purpose PII may be disclosed
4)Authorized uses and disclosures of any collected PII
5)Whether our request to collect PII is voluntary or mandatory under applicable law
6)The effects of nondisclosure if you choose not to provide requested PII

Please read this Statement carefully and contact us at [email protected] or 800-657-8033 if you have any questions or concerns.

We will take reasonable steps to ensure that any of your PII we have in our possession is compete, accurate, and up-to-date to the extent necessary to assist you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHP’s through the Marketplace, and/or applying for a Federal subsidy. We have implemented operational, administrative, technical, and physical safeguards and procedures, including privacy and security training to protect your PII and ensure its confidentiality, integrity and availability, and prevent unauthorized or inappropriate access, use or disclosure.

In accordance with our established privacy and security standards, which are publicly available upon request, you (or your authorized representative) have the right to simple and timely means of accessing and obtaining your PII in a readable format, disputing the accuracy or integrity of your PII, and having erroneous information corrected or deleted.

Legal Authority for Collection of PII
We have entered into an agreement with the Marketplace, under which we comply with the Marketplace’s privacy and security standards established by the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services. We may collect, use, or disclose your PII if and to the extent required under applicable law. In all other instances, we may collect, use, or disclose your PII, in accordance with this Statement, to the extent necessary to assist you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHP’s through the Marketplace, and/or applying for Federal subsidies.

Purpose of Collection of PII
The purpose of our collection of PII is to assist you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHP’s through the Marketplace, and/or applying for Federal subsidies.

To Whom and for What Purpose PII May be Disclosed
We may disclose your PII to the Marketplace, certain Federal or State agencies, a health insurance issuer offering a QHP that you have selected, or any individual who is duly and legally authorized to act on your behalf in connection with you PII. This includes any individuals acting under an appropriate power of attorney or appointment that complies with applicable State and Federal law. Your PII may be disclosed to the extent necessary for us to assist you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHP’s through the Marketplace, and/or applying for Federal subsidies.

Authorized Uses and Disclosures of Collected PII
We may use and disclose PII if and to the extent reasonably necessary to assist you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHP’s through the Marketplace, and/or applying for Federal subsidies. We will obtain your informed consent, which you may revoke at any time, for any other uses or disclosures of PII.

Whether Request to Collect PII is Voluntary or Mandatory under Applicable Law
Our request to collect our PII, for purposes of assisting you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHP’s through the Marketplace, and/or applying for Federal subsidies, is voluntary.

Effects of Nondisclosure of PII
If you choose not to provide the requested PII to us, then we may be unable to assist you in comparing health insurance plans, obtaining determination of eligibility for coverage, enrolling in QHP’s through the Marketplace, and/or applying for Federal subsidies.

Please contact us at [email protected] or 800-657-8033 if you have any questions or concerns regarding this Privacy Notice Statement, or our collection, use, and disclosure of PII in general.
Name*
First Last
Date*
MM slash DD slash YYYY
Signature*

Marketplace Eligibility Disclosure
Consent*
I have read and agree to the following:
If you're enrolled in a Marketplace plan and receiving tax subsidies, or other cost-sharing reductions, it is important that changes to your income and other household changes are reported immediately! *

*Certain changes, like higher or lower income, adding or losing household members, getting offers of other health coverage, or a change in status, may affect the coverage or the subsidy you are receiving.

Changes to your expected household income for the year, including but not limited to:
- Salary increases from your, or your spouse’s, current employment
- Employment changes
- Changes to income from other sources (Unemployment compensation/Social Security Disability Income/investment income/retirement or pension income/distribution from an IRA or CD, inheritance etc.)
Changes to your household or individual members, including but not limited to:
- Birth or Adoption
- Becoming pregnant
- Marriage or divorce
- Death of a family member
- Gaining/losing a dependent(s)
- Moving out of the state
Changes in Health Coverage offers during the year, including but not limited to:
- Someone in your household is offered health insurance through their employer (even if they don’t enroll in coverage)
- Someone in your household becoming eligible or receiving coverage from a public program like Medicaid, CHIP, or Medicare
Changes to your status, including but not limited to:
- Change in disability status
- Change in tax filing status
- Change in citizenship or immigration status
- Change in status as an American Indian/Alaska Native or tribal member
- Incarceration or release from incarceration
CHANGES CAN BE REPORTED THE FOLLOWING WAYS:
- Contact the Marketplace directly at 1-800-318-2596
- Contact my Agent for assistance reporting the change at 515-576-1800
This does not represent a complete list of the changes that could affect your eligibility for tax subsidies or other cost-sharing reductions. For a complete list you should visit healthcare.gov or contact your financial advisor regarding your specific tax situation.
Marketplace Eligibility Acknowledgment
Please initial to the left of each statement.
I have read and understand the importance of reporting changes as outlined in the Marketplace Eligibility Disclosure*
I understand & agree to report any changes to my household or family members*
I understand & agree to report any changes of income for myself and family members*
I understand & agree to report any changes in health insurance coverage offers made available to myself and/or family members*
I understand that by not reporting these changes, I may be subject to paying back some, or all, of my subsidy and cost-sharing when I file my federal tax return*
I do not hold the agent assisting me, or KHI Solutions LLC responsible for any information I have provided or failed to provide*
Consumer Consent Acknowledgment
I hereby grant my Agent and/or Agents within KHI Solutions permission to: Conduct an online person search, Assist with completing an eligibility application, Assist with plan selection and enrollment and Assist with ongoing account/enrollment maintenance*
I hereby certify that the information I provided on my Marketplace application for myself, and any family members, is accurate to the best of my knowledge.

I understand and agree that the Consumer Consent Acknowledgement shall continue for an indefinite term, unless I provide a written request to terminate, or the Marketplace policy is no longer in effect.
Name*
First Last
Date*
MM slash DD slash YYYY
Signature

Please note that submissions made via this website do not constitute a binding agreement of any kind. Coverage or changes in coverage are not effective or binding until you, or any party involved, receive official notice from an authorized representative of KHI Solutions or your insurance company. Misstatements or omissions of relevant information by the prospect/client can lead to price variation or even declination or rescission of coverage.

Quote Request for Private Health Insurance

Step 1 of 3

Policyholder Information

Spouse and/or Dependent Information

Current Coverage

Income Information

Privacy Notice Statement Pertaining to Personally Identifiable Information

Marketplace Eligibility Disclosure

Marketplace Eligibility Acknowledgment

Consumer Consent Acknowledgment

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First Name	Last Name	Date of Birth	Gender	Tobacco Use