Form for Updating Information for 2026 Open Enrollment Health Insurance
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  • Form for Updating Information for 2026 Open Enrollment Health Insurance

    The Open Enrollment Period for 2026 health insurance begins on November 1st. For your convenience, we have prepared a form with simple questions. Estimated completion time: approximately 4 minutes. All information is protected and HIPAA-compliant.
  • 1. Has your contact information changed (address, phone number, or email)?
  • Which specific contact information has changed?
  • Format: (000) 000-0000.
  • 2. Has your household composition changed in terms of tax filing?
  • How has your household composition changed?
  • Please indicate the person’s date of birth.
     - -
  • 3. Has your projected income for 2026 changed compared to the current year?
  • 4. Are you satisfied with the insurance company and the policy we arranged earlier?
  • 5. Have you had any unexpected medical bills or coverage issues?
  • 6. Have your preferred doctors or specialists out from network? Do you have any preferences for doctors who should accept your insurance plan?
  • 7. Do you want me to verify if your doctors will still be in-network next year?
  • 8. Do you require any specific medications or services that should be covered by your insurance plan?
  • 9. Would you be interested in exploring separate products that include the following options?
  • 10. Do you want to keep your same carrier or explore others?
  • 11. Would you like to schedule a call with your agent to review details before the Open Enrollment Period begins?
  • Annual review appointment
  • 12. Would you like to join our promotional thank-you program and get a FREE $1M Identity & Cash Theft Protection policy while helping your friends and family find the best health insurance?
  • Do you want to add something else?
  • Do you have an updated Employment Authorization, Green Card, or other supporting documents to attach?
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  • Consent & Signature

  • I {fullName} confirm my permission to Gennadii Zolotov ("Agent") 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 or State Based Exchange (SBE). 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 or SBE application
    Completing an application for eligibility and enrollment in a Marketplace or SBE Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace or SBE premiums
    Providing ongoing account maintenance and enrollment assistance, as necessary
    Responding to inquiries from the Marketplace or SBE 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.

    Agent name: Gennadii Zolotov

    Agent NPN: 21076241

    Agent phone: (305) 775-3215

     

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