CONSENT:
All calls may be monitored or recorded.
As primary contact, I hereby appoint TXInsurance .Com Agency LLC (NPN 8982704), Joseph Stevens (NPN 7885847) and / or Hellen Stevens (NPN 7965574) "Agents", principal office Texas, USA to serve as my health insurance broker(s) for myself and entire household, for purposes of enrollment in a Qualified Health Plan and / or other related products.
As Primary Contact, I hereby appoint the health insurance agent(s) referenced above (“Agents”) to represent me and, if applicable, my entire household for the purpose of my/our enrollment in a Qualified Health Plan on a Federal Facilitated Marketplace. Through this appointment, I authorize and consent to Agent(s) viewing and using confidential information provided by me in writing, electronically, or by telephone, for the purposes of one or more of the following or any other reasonable related task:
Searching for an existing Marketplace application;
Completing an application for eligibility and enrollment;
Viewing and /or processing account changes as requested by client or marketplace;
Viewiing and /or processing account annual renewal information or changes;
Providing ongoing account maintenance and enrollment assistance;
Processing initial payments and conducting related account tasks with insurer or marketplace;
Responding to inquiries from the Marketplace regarding my Marketplace application.
Agent(s) will not use or share my personally identifiable information, including but not limited to, protected health information (collectively, “PII”) or, if applicable, that of my household members for any purpose other than those listed above. Agent(s) will ensure that any PII provided Agent(s) pursuant to this representation will be kept private and safe when collecting, storing, and using the PII for one or more of 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 or, if applicable, that of my household members with Agent(s) beyond what is required to complete my Marketplace eligibility and enrollment application. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time.
I understand that the purpose of this consultation is to discuss and analyze my and, if applicable, my household members’ insurance needs and requirements. Agent(s) will provide information about various insurance policies, coverage options, and other related matters to assist me in making informed decisions regarding insurance coverages.
I understand during the consultation, Agent(s) will review my personal and financial information to assess my insurance needs accurately. This may include discussions about my current insurance policies, financial situation, and any specific requirements I may have.
I understand I must attest and agree to file a tax return and form 8962 to reconcile any given APTC (advanced premium tax credit, aka "subsidy").
Please consult with a CPA or legal professional for any tax or legal concerns.
We DO NOT give tax or legal advice.
I understand Agent(s) will provide recommendations based on the information I provide and their analysis of my insurance needs. It is my responsibility to carefully consider these recommendations and make decisions that best suit my requirements.
I understand this consultation is provided without any obligation to purchase insurance policies or services from Agent(s).
I understand that, while Agent(s) will provide professional advice to the best of their knowledge and expertise, it is important to acknowledge that insurance coverage decisions involve uncertainties and potential risks. I hereby agree to hold my agents/agency listed above harmless from any errors or ommissions.
By signing below, I acknowledge that I have read, understand, and agree to the terms and conditions outlined in this Consent Agreement.
Agency Fee Legal Disclosure Statement
TXInsurance.com Agency LLC
Office of Joseph & Hellen Stevens
National Producer Numbers:
Joseph Stevens – NPN # 7885847
Hellen Stevens – NPN # 7885848
Disclosure Statement
This disclosure is provided pursuant to Sections 550.001, 4005.003, and 4005.004 of the Texas Insurance Code.
Our agency may charge a flat Agency Fees as listed below for assistance in reviewing, comparing, and maintaining Affordable Care Act (ACA) Marketplace or other health insurance coverage.
$39 (During Open Enrollment November 1-December 15)
$59 (After December 15 and all other dates)
$99 (Employer Small Group Health Insurance)
This fee is voluntary and separate from any premium charged by your selected insurance company.
You are under no obligation to pay this fee. Consumers may always apply for ACA Marketplace coverage directly at www.HealthCare.gov at no charge.
This agency fee may be in addition to other compensation our agency receives from an insurance company or other third party. If we receive both a fee from you and compensation from an insurer for the same enrollment, this statement serves as notice that such compensation may include commissions, bonuses, or other standard industry compensation arrangements.
Standard and Additional Services Included
(over 20 years of experience analyzing health plans)
• Enrollment and comparison of all available insurance carriers
• Detailed processing of small group employer onboarding paperwork
• Review of hospital networks, doctor access, and prescription coverage
• Explanation of deductibles, out-of-pocket limits, and plan benefits
• Review and submission assistance for eligibility notices
• Guidance on HSA-compatible Bronze plan options (upon request)
• Assistance retrieving your annual Form 1095 (if available and requested)
COMPENSATION:
Agent(s) and/or the Agency may receive compensation from ACA Marketplace and Off-Marketplace health insurance carriers.
ACA on and off marketplace Health Insurance: Compensation typically averages $20–$25 per member per month, with the potential for additional bonus compensation based on production.
Ancillary Products: We may also receive compensation for ancillary products such as dental, vision, Medicare, life insurance, and other coverage types. For example, dental insurance generally pays 10–20% of your premium on an ongoing basis, and some carriers may offer higher first-year commissions.
Small Group Insurance: Compensation may be structured either as a per-employee-per-month payment (approximately $20–$30) or as a percentage of premium, such as 4.5% ongoing, with additional compensation for ancillary benefits such as dental, vision, or life coverage.
SMS / TEXT NOTIFICATIONS:
By submitting this form, you consent to receive general and / or account related text messages from Agent(s) TXInsurance .Com Agency LLC, Joseph Stevens or Hellen Stevens, (i.e renewing coverage, billing information, coverage changes, price changes, product changes, etc.,) at the number or number(s) provided. We do not send out spam texts only conversational texts relating to your account.
This agreement will remain in effect until explicitly revoked by faxing 210-590-1989 or emailing joe@txinsurance.com and receiving a confirmation from our agency that such revocation was received.