SunriseHealth Enrollment
ENES(305) 555-0148

Read it back to yourself.

This is everything we have. Change anything that is not right, then sign to say it is true.

Stage 5 of 6Review

  1. Survey
  2. Plans
  3. Consent 1
  4. Consent 2
  5. Review
  6. Done

Where you live

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Household

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Income

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Prescriptions and providers

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Your plan

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Contact and consent

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Your attestation

English

This is everything we have. Change anything that is not right, then sign to say it is true.

I, [First Name] [Last Name], have reviewed the household, income, prescription, provider and plan information shown on this page. I confirm that it is true, correct and complete to the best of my knowledge.

I understand that the information above will be used to complete an application for eligibility and enrollment in a Qualified Health Plan, and that giving false or untrue information on a Marketplace application can affect my eligibility and my coverage.

I understand that the plan shown here is the plan I am asking my agent to enroll me in, that the premium and the estimated tax credit shown are estimates produced from the information I gave, and that the Marketplace makes the final eligibility determination.

I understand that this is a demonstration website. Nothing on this page is submitted to the Marketplace, to CMS or to any insurance company, and no coverage of any kind is created by signing it.

sunrise-application-attestation-2026.1

Sign here

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What is recorded with your signature

A signature is only worth something if there is a record of what was signed and by whom. Here is the whole list. There is nothing else, and nothing hidden.

Recorded by our server

Collected by Cloudflare when your browser makes the request. You cannot change these, and neither can we.

  • The time the request arrived, in UTC
  • Your IP address
  • The country, region, city and postal code Cloudflare associates with that address
  • Your network operator and its ASN
  • Which Cloudflare data centre answered
  • The HTTP protocol and TLS version used
  • The time zone Cloudflare associates with that address
  • The full user agent string your browser sends
  • The languages your browser asks for
  • The page you came from
  • A reference number generated for this record

Reported by this page

Read in your browser and sent up with the form. Labelled as client reported, because a browser can be told to say anything.

  • Your clock, in UTC and in local time
  • Your time zone and its offset from UTC
  • The languages your browser is set to
  • Your platform and browser, as your browser describes them
  • Your screen size and colour depth
  • The size of this window
  • Your device pixel ratio
  • Your reduced motion, colour scheme and pointer settings
  • The page you landed on, this page, and the page that sent you here
  • How long you spent on each step, and in total
  • The version and SHA-256 hash of each consent text you were shown, and in which language

Why the hash matters

The hash is a fingerprint of the exact words on this page. If a single character of the consent changed, the fingerprint changes. It is what proves later which text you agreed to, and the record says which language version you were reading when you agreed to it.

Your signature itself

The picture of your signature stays in this browser. What goes to the server is its SHA-256 hash, its size and how much ink is on it, which is enough to bind this record to the mark you made. The picture is put back into the copy you download.

What is deliberately not collected No canvas or WebGL fingerprinting, no font enumeration, no audio fingerprinting, and no other covert device signal. An audit trail records something you chose to do. It is not a tracking apparatus, and building one here would undermine the consent this form exists to collect.
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Nothing here is sent anywhere. Demonstration. No application is transmitted to CMS or any carrier.
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