I give my permission to Ryan Surjnarine 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 premiums; Providing ongoing account maintenance, yearly renewals, enrollment assistance, as necessary; or Responding to inquiries from the Marketplace regarding my Marketplace application for the next 60 months. 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 provided the Agent and the information used on my application is true and accurate. 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 contacting my Agent at the following email address; ryan@uhealthbenefits.com.

 

Name of Primary Writing Agent: Ryan Surjnarine
Phone Number: 888-405-5416
Email Address: ryan@uhealthbenefits.com
Agent NPN: 19233804

 

By submitting this document, you agree the above information is true and accurate. 

PLEASE CLICK THE RECORD BUTTON BELOW THEN CLICK STOP WHEN YOU ARE DONE. IF YOU GET A NOTIFICATION FOR THE APP TO USE YOUR MICROPHONE, PLEASE CLICK ALLOW. YOU WILL ALSO NEED TO KNOW TODAY'S DATE BEFORE READING THE STATEMENT BELOW.

 

PLEASE RECORD THE FOLLOWING:

 

I ____________, born on ______________, give permission to Ryan to enroll me into this marketplace plan based on myself, meeting the minimum income requirements for this $0 Premium health coverage. Today's date is ______________, and I confirm that I am the applicant.

By signing the box below, you attest to the following: 1) This is a request to be enrolled in an affordable qualified health plan in your area-based - market. 2) We will enroll you once the information has been verified via phone call. 3) This is a request to have Ryan Surjnarine or their designee, to take over as your agent of record from this point forward unless written notice is provided. 4) This is authorization for Ryan Surjnarine or their designee to reach out via sms, email, or in rare cases, call to provide updates or request information for the application as needed. PLEASE SIGN THE BOX BELOW TO APPROVE OF THESE TERMS AND CONDITIONS

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.