On behalf of Susan Polk Insurance Agency, Inc., (“SPI”) we would like to thank you for choosing us. We appreciate the opportunity to serve you. This letter will set forth our engagement, including a disclaimer and waiver regarding electronic data transfers.
The individual named below hereby allows Susan Polk Insurance Agency, Inc., to be his/her broker for enrolling in health insurance and for providing service. During the course of this relationship, SPI may have access to Client’s personal health and income information. It is agreed that:
Susan Polk Insurance Agency, Inc., will comply with the security and data privacy provisions enumerated in The Health Insurance Portability and Accountability Act (“HIPAA”) of 1996;
If requested, Client will sign applications and/or other documents electronically in a timely manner;
In the course of our relationship, SPI may conduct electronic data transfers, including setting up passwords, on Client’s behalf using third-party internet sites, such as Medicare and/or Covered California. These passwords will be safeguarded, and shared with Client;
With regards to said data transfers and passwords, CLIENT agrees that
Susan Polk Insurance Agency, Inc., shall have no liability for any loss or damage to any person or entity resulting from the use of electronic data transfers, as well as any consequential, incidental, direct, indirect, or special damages, or disclosure or communication of confidential or proprietary information.
The terms of this engagement will remain in force until otherwise modified.
Susan Polk Insurance Agency, Inc.
I have read, understand and agree to the above statements.