I , give my permission to AJM Associates, Inc., Karl J. Ruth Jr., NPN 7267003, to serve as the health insurance Agent of Record or Broker of Record for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. This form replaces any other authorization that may have been previously completed for purposes of Agent of Record designation.
By consenting to this agreement, I authorize the above-mentioned Agent or Broker 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:
Search for an existing Marketplace application;
Complete an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid or CHIP or advance tax credits to help pay for Marketplace health insurance premiums;
Provide ongoing account maintenance and enrollment assistance; or
Respond 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.
By signing hereunder, you confirm, acknowledge, and understand your current health insurance agent, if applicable, will be replaced by Karl J. Ruth Jr., NPN 7267003 for purposes of Marketplace Health Insurance.
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 notifying AJM Associates, Inc. in writing via e-mail or postal mail. This attestation has been reviewed and signed by me and is true and accurate to the best of my knowledge.
