Health Insurance Marketplace - Consent for Agent/Broker Assistance Consumer Name: Date of Birth: 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 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 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. I accept
