Schedule Phone Call First Name (required) Last Name (required) Gender (required) MF Date of Birth (required) State Zip (required) Email (required) Phone (required) YES! I give consent. Help me with my Marketplace Account. Consent Form for Assistance with Marketplace Health Insurance Yes, I understand by checking the agreement box I allow access to my Marketplace Account. I give my permission to Licensed and Certified FFM Agent Andrew Bennett NPN 10224328 to serve as the 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 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 an existing Marketplace application -Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace or State Based Exchange premiums -Providing ongoing account maintenance and enrollment assistance, as necessary -Or responding to inquiries from the Marketplace regarding my Marketplace application -Acting as my sole Agent of Record on the chosen insurance policy 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 for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I also understand it is my duty to notify the agent or Marketplace / State Based Exchange if my income changes. Once an eligibility application is submitted, my stated income will be listed on the eligibility notice. If my income or tax filing changes, I understand I must contact my agent or Marketplace / State Based Exchange immediately to update the income status on my eligibility application. Name of Primary Writing Agent: Andrew Bennett NPN 10224328 Phone Number: 4199316514 Email Address: [email protected] I understand that my consent remains in effect until I revoke it. I may revoke or modify my consent at any time by emailing my agent. It is my duty to notify Andrew Bennett if I decide to work with another agent. Andrew Bennett cannot be held responsible for application changes performed by another agent or policy changes that occur without his assistance. I understand that an annual review is advised, so the Agent can help me review potential income or tax filing changes and potential changes to plan offerings. Free Service: I understand there is no cost associated with utilizing the assistance of a Marketplace / State Based Exchange Agent. Cancellation: You are welcome to cancel your Marketplace OR State Based Exchange plan at any time by calling the number on your insurance card. Termination dates cannot be backdated.