I, {primaryApplicant}, give my permission to the agent/agencies listed below 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.

-One Stop Health Inc: NPN 21103144	-PremierShield Insurance: NPN 21314081
- Cole Ryan Havrilesko: NPN 18383924	- Svetlana Bakhtiyarova: NPN 21131832
- Corey Havrilesko: NPN 20848757	- Zachary Jones: NPN 18401162
- Kyle Havrilesko: NPN 21249124	- Spencer Jones: NPN 21390428
- Cheryl Havrilesko: NPN 20864209	- Jesse Maguetta: NPN 19442623
- Frank Havrilesko: NPN 21247524	- Aaron Margolis: NPN 19104215

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 phone only for one or more of the following:

• Searching for an existing Marketplace application.
• Completing an application for eligibility and enrollment.
• Providing ongoing account maintenance and enrollment assistance.
• Responding to inquiries from the Marketplace regarding my 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.

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.

I understand that the below printed name takes the place of my signature on this form.

{primaryApplicant}