I have reviewed the information provided in the Marketplace eligibility application and confirmed its accuracy prior to submission. The broker explained the attestations at the end of the application, and I was given the opportunity to ask questions and receive clarifications.
I understand that the broker will not use or share my personally identifiable information (PII) for any purpose other than those for which I have given explicit consent.
The broker will take all necessary steps to ensure that my PII remains private and secure when creating, collecting, disclosing, accessing, maintaining, storing, and using my information for the purposes I have authorized.
I also understand that I am not required to share additional PII or protected health information (PHI) beyond what is necessary to determine eligibility and enrollment in the Marketplace.
Agent Information
Name of Primary Writing Agent: Sonia Beato
Agent National Producer Number: 3664315
Phone Number: +1 7862229996
Email Address: sbeato@1keyinsurance.net
Authorized Assistant:
Name:
Phone:
Email:
Primary Household Contact and/or Authorized Representative:
Name:
Phone Number:
Email Address:
Address: APT #: ZIP Code:
Plan: Prima:
Marital status:
Projected Annual Family Income:
Number of people on your tax return:
