Consumer Consent & Eligibility Form for Marketplace Client Applications I,(Required) First Last give my consent to WILLIAM STEFFEN (or Antoinette Steffen), to serve as my health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent(s) to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: Searching for my existing Marketplace application, completing my application, updating data like address or email or phone, adding or removing household members, submitting income or immigration documents, processing initial or ongoing payments, reviewing current and renewal plan options for coverage, determining eligibility for premium tax credits to help pay marketplace premiums or Medicaid/CHIP eligibility, and any other related tasks as needed. I give permission to the Agent to access my Personally Identifiable Information (PII) that is necessary to determine eligibility for health insurance and to enroll into a health plan, including but not limited to my name, home address, email address, phone number, date of birth, social security number, financial information, and employment information. This includes all family members on the application for whom you have authority to do so. I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provide during our phone appointment for Marketplace application submission will be accurate to the best of my knowledge, including household income projections for the next tax year, legal names, and social security numbers. I understand that the Marketplace will retrieve information about me from different data sources to confirm eligibility including future tax returns up to 5 years. I agree to inform my agent or the Marketplace when I become eligible for other insurance like employer group plans, Medicare, Medicaid or CHIP. I understand I do not have to share additional personal information about myself beyond what is required on the application for eligibility and enrollment purposes. I confirm that I have reviewed the application contents, attestations, and eligibility results for accuracy before application submission on the date of our call. I understand that my agent gets compensated by the insurance company directly via commissions. The insurance premium you pay is the same whether you use an agent or not; therefore, our agent services and advice comes at no cost to you. While every company and plan compensate differently, the average is about twenty dollars per month per member with possible bonuses based on production. The specific amount received related to your insurance policy is available upon request. I understand that this consent remains in effect with no expiration date. I can revoke my consent at any time by email only to ([email protected]) Please review:(Required) BY CHECKING THIS BOX I AGREE TO THE ABOVE Sign (Type) Your Name:(Required) First Last Please ensure your signature matches the name provided above.Date Signed: Name of Primary Writing Agent: WILLIAM A STEFFEN Agent National Producer Number: 7939021 Office Phone Number: 928 252 2493 Email Address: [email protected] Name of Secondary Writing Agent: Antoinette Steffen Agent National Producer Number: 8914487
