I agree to give my permission to The Best Rate Insurance 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, live or by telephone only for the purposes of one or more of the following:
1. Searching for an existing Marketplace application;
2. 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 premiums;
3. Providing ongoing account maintenance and enrollment assistance, as necessary; or
4. Responding to inquiries from the Marketplace regarding my Marketplace application.
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 understand
that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by email, text or
written letter.
This document will be held either in paper or digital format by the Agent for no less than 10 years.