Health Insurance Marketplace - Consent for Agent/Broker Assistance Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Application Marketplace (if Consumer Name: *Marketplace Application Id (if available): *Name of Primary Writing Agent: Wisner Jean Agent National Producer Number: #19554942 Phone Number: (561) 255-0728 Email Address: info@wizemultiservices.com Purpose of Consent I, **I understand my personally identifiable information (PII) will be used only to carry out the tasks I’ve authorized and will be kept secure and confidential. Duration & Revocation This consent is valid until I revoke it. I can revoke my consent at any time by notifying the agent/broker or the Marketplace. Allow the above-named agent/broker to: Search for my existing Marketplace application Complete an eligibility and enrollment application Help me select a Qualified Health Plan Provide account maintenance and enrollment assistance Respond to inquiries from the Marketplace regarding my application Privacy Statement Signature Clear Signature I accept *I acceptSubmit
