By signing this for I, applicant/policyholder, agree to the plan’s benefits and terms. A representative of  Texas Wide Insurance Services  will provide  health plan’s monthly premiums, deductibles, and out-of-pocket costs. I am aware that my monthly subsidies from the Affordable Care Act is based on my household size and stated yearly income. I understand the financial information I provided to my enroller/advisor is required to reflect the incomes I will file with the IRS for the present year. I am aware that any failure to report life changes based on income, household size, etc.