First Name (required)

Last Name (required)

Gender (required)

MF

Date of Birth (required)

State

Zip (required)

Email (required)

Phone (required)

YES! I give consent. Help me with my Marketplace Account.

Consent form to assist with Marketplace Health Plan Enrollment
Yes, I understand by checking the box I will allow certified agent access to my Marketplace Account and FREE assistance with reviewing plan information, updating address, updating income, and help maintaining my Marketplace Health Insurance account. Certified Agent can also assist during renewal and when information needs updated. In the event my income or household tax filing changes, it is my duty to contact my agent or the Marketplace in a timely manner. I give consent for agent to create, collect, disclose, access, maintain, store, and/or use my Personally Identifiable Information (PII) needed to carry out the roles and responsibilities of a licensed insurance agent and act on my behalf. Agent can conduct a search for my consumer application through the Marketplace and be listed as agent of record on the policy. Agent can also assist with completing an eligibility application, assist with plan selection and enrollment, assist with ongoing account/enrollment maintenance. I understand that I can revoke, limit, or otherwise change the consents I allocate through this form at any time. I understand this service is FREE to me as a legal resident of the United States.

First Name (required)

Last Name (required)

Gender (required)

MF

Date of Birth (required)

State

Zip (required)

Email (required)

Phone (required)

YES! I give consent. Help me with my Marketplace Account.

Consent form to assist with Marketplace Health Plan Enrollment
Yes, I understand by checking the box I will allow certified agent access to my Marketplace Account and FREE assistance with reviewing plan information, updating address, updating income, and help maintaining my Marketplace Health Insurance account. Certified Agent can also assist during renewal and when information needs updated. In the event my income or household tax filing changes, it is my duty to contact my agent or the Marketplace in a timely manner. I give consent for agent to create, collect, disclose, access, maintain, store, and/or use my Personally Identifiable Information (PII) needed to carry out the roles and responsibilities of a licensed insurance agent and act on my behalf. Agent can conduct a search for my consumer application through the Marketplace and be listed as agent of record on the policy. Agent can also assist with completing an eligibility application, assist with plan selection and enrollment, assist with ongoing account/enrollment maintenance. I understand that I can revoke, limit, or otherwise change the consents I allocate through this form at any time. I understand this service is FREE to me as a legal resident of the United States.