1. Collection of Data.
Our process requires a significant amount of information collection in order that we may appropriately serve you. Required fields are indicated. Providing us with other information is at your option. Please take note that your name, e-mail address, or other submissions that you make on this site may contain your real name or other personally identifiable information. Like many web sites, we may also automatically receive general information that is contained in our server log files such as your IP address and cookie information. Information about how advertising may be served on this site (if at all) is set forth below.
2. Use of Data.
We do not allow persons who are ages eighteen or younger to submit information to this site.
5. Editing or Deleting Your Account Information.
We may make changes to this Policy from time to time. We will notify you of substantial changes to this Policy either by posting a prominent announcement on our site and/or by sending a message to the e-mail address you have provided to us that is contained within your user settings.
7. No Guarantees.
8. Contact Information.
If you have any questions about this Policy or our web site, please feel free to contact our webmaster.
9. Privacy Notice Statement regarding Health and ancillary coverage.
We are authorized to collect personal identifiable information (PII) from you by the state of Michigan, and our contracted companies. Any PII Arbury Insurance Agency (and Michigan Insurance Associates) collects is used to assist you with coverage servicing. If you choose to give us PII, voluntarily, we may share this information with contracted companies to assist you with policy servicing. PII is used or disclosed only under the following circumstances: coverage servicing including quoting and enrollment. If PII is not disclosed, coverage servicing will be incomplete. You may access our complete Privacy Statement Pertaining to PII here.
Prequalification Application – Health Insurance Marketplace Disclosure
I have 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.
If my Marketplace Eligibility Notice tells me to send more information, I will follow the instructions by the deadline. If I don’t, I could lose what insurance I qualify for now. I may not be able to enroll in a Marketplace plan until the next Open Enrollment Period, in November 2019.
I know I must tell the Marketplace if information I listed on this application changes. I know I can make changes in my Marketplace account online or by calling 1-800-318-2596. I know a change in my information could affect eligibility for member(s) of my household.
If my insurance is cancelled due to nonpayment, I won't be able to enroll in a Marketplace plan until the next Open Enrollment Period, in November 2019.
I understand when I file my tax return; the IRS will compare the income on my tax return with the income on my application. If my income is higher than reported, I may owe additional federal income taxes.
I will file a federal income tax return next year, for this year. If I am married, I will file joint with my spouse. No one else will claim me as a dependent.
I will claim a personal exemption deduction on my federal income tax return for any individuals listed on the application as a dependent who is enrolled in coverage through the Marketplace.
Prequalification Application – Acknowledgement to Review Notice of Privacy Practices
I understand, and provide my consent, to have Arbury Insurance evaluate different individual health insurance options on my behalf. I provide my consent and allow Arbury Insurance to use information contained on this form to execute an enrollment on my behalf based on the plan I verbally select with my agent. I declare that the answers and information presented on this application are complete and true for all applicants to the best of my knowledge and belief, and will be used as the basis for issuing coverage and determining my eligibility for an “Advanced Premium Tax Credit” (APTC) from the Health Insurance Marketplace. I understand that I should not cancel any current coverage I currently have in place until I receive written notice of approval from Arbury Insurance. I understand that any person who, knowingly and with intent to defraud any insurance company or other governmental entity, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act when determined by a court of competent jurisdiction, and as such may be subject to criminal and civil penalties. I understand that this coverage is not an employer group health plan and is not intended to be an employer-sponsored health insurance plan. I certify that my employer will not contribute any funds toward the cost of this coverage.