Agent on Record Agreement

Agent/Agency Agreement

You understand that you give your permission to the assisting agent/agency (FreedInsure Agency or any associated representatives) to serve as the health insurance agent or broker for yourself and your entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace.  You understand that the named broker of record on your application may be different than the writing/assisting agent/broker. By consenting to this agreement, You authorize the above-mentioned Agent to view and use the confidential information provided by yourself 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 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;
3. Providing ongoing account maintenance and enrollment assistance, as necessary; or
4. Responding to inquiries from the Marketplace regarding your Marketplace application.

Privacy Agreement 

You understand that the Agent will not use or share your personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that your PII is kept private and safe when collecting, storing,  and using your PII for the stated purposes above.

Consumer Attestation

You confirm that the information You provide for entry on your Marketplace eligibility and enrollment application will be true to the best of your knowledge. You understand that you do not have to share additional personal information about yourself or your health with your Agent beyond what is required on the application for eligibility and enrollment purposes. You understand that your consent remains in effect until you revoke it, and you may revoke or modify your consent at any time by written request to clientrelations@freedinsure.com