I, , have reviewed the Marketplace eligibility application information and confirmed its accuracy prior to the application being submitted. The agent explained the attestations at the end of the eligibility application to me prior to the application being submitted and I was given an opportunity to ask questions about them.

I understand that the agent will not use or share my personally identifiable information (PII) for any purposes other than those to which I consented. The agent will ensure that my PII is kept private and safe when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the purposes I consented to.

I understand that I do not have to share additional PII or protected health information (PHI) with my agent beyond what is required on the Marketplace application for eligibility and enrollment purposes.

Name of Primary Writing Agent:
Agent National Producer Number:
Phone Number:
Email Address:

Name of Primary Household Contact and/or Authorized Representative:
Phone Number:
Email Address:
Address: APT #: ZIP Code:
Carrier: Florida Bule. Plan:
Marital status:
Projected Annual Family Income:
Number of people on your tax return:
Plan:
Prima:

I confirm that I have NO other medical insurance, as well as that I have no offer in my job of medical coverage.

I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by sending an email to

Signature:

By signing above, I acknowledge that I have fully read and fully understand the Enrollment Authorization:

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility