Attestation with GetCoveredNJ Application
GCNJ will present this agreement prior to you signing and submitting your GCNJ eligibility application. 
Read and check the box next to each statement if you agree:


* Are any applicants incarcerated (in prison or jail)?

* To make it easier to reduce my health insurance coverage cost in future years, I agree to allow GetCoveredNJ to use sources, such as the Internal Revenue Service (IRS), to check my income and to use that data, including information from my tax returns, to determine whether I am eligible to continue to receive financial help. If those sources show I am still eligible for continued financial help, my insurance coverage and financial help will be renewed for another 12 months. I understand GetCoveredNJ will send me a notice explaining that my coverage has been renewed and allow me to make any changes necessary. I acknowledge if I elect not to give this consent, my insurance will be renewed without financial help for the following year. I also acknowledge I can discontinue, change, or otherwise opt out at any time.


* I understand that if anyone on my application enrolls in a Marketplace health plan and is later found to have other qualifying health coverage (including Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace health plan.


* I understand that any financial help I receive from the federal government through Advance Premium Tax Credits is connected to my taxes. I understand I may owe taxes, or receive more tax credit, if my income for the year is different than what I estimated. I agree to file federal income taxes (jointly if married) and report the amount of Advance Premium Tax Credits received on my Tax Return for any year I have federal financial help to lower premium costs.


* If a child on this application has a parent living outside of the home, I know I’ll be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell the agency and I may not have to cooperate.


* I understand that I have 30 days to notify the Marketplace of any change of information in this application. I will report any changes within this time period. I understand that changes in my income, household size, address or other details might affect my or my household's eligibility for specific benefits. I understand and will notify the Marketplace if my application information change.


* I understand that my application will be used to evaluate eligibility for health coverage through GetCoveredNJ or Medicaid (NJ FamilyCare). If I enroll in Medicaid, I acknowledge that the NJ Division of Medical Assistance and Health Services can file a claim and lien against the estate of a deceased Medicaid beneficiary to recover all Medicaid payments for services received on or after age 55 Estate Recovery - What You Should Know. I understand that estate recovery only applies to Medicaid and it is not applicable to enrollment in a health plan through GetCoveredNJ. If anyone on this application enrolls in Medicaid, I’m giving the Medicaid agency the right 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.



* By typing my name in the box below, 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.

GetCoveredNJ - Electronic Signature for Your Enrollment


Enrollment Terms and Conditions

To complete the checkout process, read the Marketplace Agreement below and type your full name in the space below to sign the agreement. Your full name in the box below constitutes your "eSignature" and it means that (i) you are sure about the plans you selected, (ii) you have read all terms and conditions, and (iii) you are indicating your intention to create a legally binding and enforceable contract.

If you are eligible for and have chosen to use some or all of your premium tax credit, you must review and accept the statements related to premium tax credits and federal income taxes.

When you click Enroll, GetCoveredNJ sends your information to the insurance company who offers your plan. You may have the option to make your initial payment after selecting Enroll depending on the insurance company for your plan. If the initial payment cannot be made at this time, the insurance company will contact you for payment and to finalize enrollment.

If you have been terminated for non payment of premiums by a health insurance company on the Marketplace, your new enrollment may be denied at the company’s discretion.

Important: Please verify your providers and drug benefits directly with your health insurance company prior to receiving care as there may be changes throughout the year.


I. Marketplace Agreement

I understand that I am required to submit changes that affect my eligibility, including income, dependency changes, address, and incarceration. These changes could affect the plans in which I can be enrolled. Outside of the Open Enrollment period, I cannot change plans unless I have a qualifying life event, such as moving, getting married, or having a baby.   I understand that the health plan coverage documents outline terms and conditions of coverage.   I have read and agreed to the Marketplace Agreement


II. Tax Filer Agreement
I agree to file a yearly Tax Return before April 15 to claim the Premium Tax Credit. I understand that I am required to submit changes that affect my eligibility, including income, dependency changes, address, and incarceration. These changes could affect the plans I can be enrolled. I cannot change plans unless I have a life-triggering event.

I agree to file a yearly tax return before April 15 to claim the Premium Tax Credit.

Application Filer Signature

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Christopher S. Kudryk
Insurance Specialist

KBenefits specializes in health, dental, vision, life and medicare insurance for employers and individuals in NJ & NY.

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