Consent Form Thank you for the confidence you have placed in our agency to assist you with your insurance needs. Please read this page and complete the below consent form. As your broker, we may collect, disclose, assess, maintain and/or store personal information. Your information may be used to perform the following: By submitting this form you consent to. 1. Assist with plan comparisons and selection. 2. Assist with applications for eligibility with insurance carriers we represent and may also include a Marketplace qualified heal plan (QHP). 3. Submit on behalf of applicant, application for insurance electronically or by paper application. 4. Facilitate payment of the initial premium amount on behalf of the applicant. 5. Facilitate an enrollee’s ability to dis-enroll. 6. Educate consumers, applicants and enrollees on insurance affordability programs. 7. Assist an enrollee’s ability to report changes in eligibility status throughout the plan year. 8. Correct errors on the behalf of the applicant/enrollee. 9. Contact insurance carrier on the behalf of the enrolled to render assistance with policy. Consent * Yes I give consent Name * First Name Last Name Email Phone * (###) ### #### Date * MM DD YYYY Thank you for your Consent Form submission.
