Consent

I authorize Agent or Agency Name to be my health insurance agent for myself and my household. This allows Agent or Agency Name to enroll me, or my family, in a Qualified Health Plan on the Federally Facilitated Marketplace. By agreeing to this, I give permission for Agent or Agency Name to use my confidential information for the following purposes:

1. Search for an existing Marketplace application.

2. Complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs.

3. Provide ongoing account maintenance and enrollment assistance.

4. Respond to inquiries from the Marketplace regarding my application. The Agent will keep my personal information private and secure, using it only for the purposes listed above. I confirm that the information I provide on my application will be accurate to the best of my knowledge. I understand that I am not obligated to share additional personal information beyond what is required for the application. I can revoke or modify my consent at any time by emailing Agent or Agency Email

   I acknowledge your request to enroll me in the most suitable health plan available based on your expertise. If zero premium plans are unavailable, I authorize you to enroll me in the next best available plan. I grant you access to my healthcare.gov account for submitting necessary information. By signing below, I confirm my understanding and agreement to the terms outlined in this attestation.

Agent of Record: Agent or Agency Name

NPN: Agent or Agency NPN

Phone Number: Agent or Agency Phone Number

Email Address: Agent or Agency Email Address

You may use your finger to sign below