I give permission to agent ______________ to collect, disclose, access, maintain, store, and/or use my PII in order to carry out the roles and responsibilities of an Agent. The roles and responsibilities of an Agent include but are not limited to the following:
1. Help me understand coverage options.
2. Assist with obtaining eligibility determination thru the Marketplace.
3. Allow agent to conduct a person search using EDE tool for the purpose of applying for Marketplace coverage.
4. Guide me with enrollment and plan selection.
5. Conduct an online person search.
6. Assist with completing a Marketplace application.
7. Assist with ongoing account/enrollment maintenance.
I understand an insurance agent is not a tax advisor or attorney and cannot provide tax or legal advice within their capacity as an agent.
Date and Time