Marrero Group Health Insurance

Name of Client*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email Address *

Month of Birth*

Day of Birth*

Year of Birth*

Gender*

Client's Medicare Identification Number*

Client's Medicaid Number(If Applicable)

Client's Social Security Number*

Physician/Primary Dr. Name

Do you take any prescription drug medication?

YesNo

Would you prefer a home or office appointment?

homeoffice

Need Life Insurance*

Name of Insurance Company (If currently insured through Medicare)*

I give my permission to Marrero Group PLLCto serve as myhealth insurance agent for myself and my entire household if applicable, forpurposes 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 byme in writing, electronically, 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 enrollmentin 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. 4. Responding to inquiries from the Marketplace regarding my Marketplace application.5. If you already have a Marketplace plan, you give permission to switch you to a better plan if one is available, if you are already on the best plan possible you are requesting Charletta Marrero (Marrero Group PLLC) to take over as your agent of record from this point forward unless notified of a change.6. I agree that if I am making less than 100% of the federal poverty line that I am looking for work making at least minimum wage. I understand that the agent will not use or share my personal identifiable information (PII) for any purposes other than those listed above. The Agent will ensure my PII is kept private and safe when collecting, starting, and using my PII for stated purposes above. I confirmthat the information I provided for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understandthat I do not have to share additional personal information about myself or myhealth with my Agent beyond what is required on the application for eligibilityand enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or notify my consent at any time by sending an email, text, or phone call to Marrero Group PLLC at +1-844-529-3095 Name of Primary Writing Agent: Charletta Marrero Agent National Producer Number: 1661882 Phone Number: +1-1844-829-3095 Email Address: info@marrerogroupllc.com

Signature*

Marrero-Group PLLC Health Insurance