I, , authorize my agent, , to provide my personal demographic information to broker Sonia Beato, who will serve as the health insurance broker for myself and my entire household, if applicable, for the purpose of enrolling in a subsidized or non‑subsidized health plan based on my income and in accordance with ACA qualifications.
By consenting to this agreement, I authorize broker Sonia Beato to view and use the confidential information I provide—whether in writing, electronically, or by phone—solely for the purposes of eligibility determination, enrollment, and related Marketplace activities.
I have reviewed the Marketplace eligibility application information and confirmed its accuracy prior to submission. The broker explained the attestations at the end of the application to me, and I was given the opportunity to ask questions and receive clarification.
I understand that the broker will not use or share my personally identifiable information (PII) for any purposes other than those to which I have explicitly consented. The broker will take all necessary measures to ensure my PII is kept 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 any additional PII or protected health information (PHI) beyond what is necessary for Marketplace eligibility and enrollment.
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:
Plan: Prima:
Marital status:
Projected Annual Family Income:
Number of people on your tax return:
