Consent to Enrollment; Verification of Information *
Appointment of Health Care Market Quotes as Authorized Representative / Power of Attorney:
DISCLOSURES REGARDING LIMITED POWER OF ATTORNEY
The following limited power of attorney authorizes Health Care Market Quotes to make decisions concerning your health insurance. This limited power of attorney does not authorize Health Care Market Quotes or any other person to make decisions about your medical care.
The following limited power of attorney becomes effective immediately upon signing. If Health Care Market Quotes is unable or unwilling to act for you after you sign the limited power of attorney, we will notify you and this power of attorney will end.
Please review the limited power of attorney carefully. If you have questions about the power of attorney or the authority you are granting to Health Care Market Quotes you should seek legal advice before signing this form.
FORM OF LIMITED POWER OF ATTORNEY
I grant Health Care Market Quotes limited authority to take any and all actions to select, procure, and maintain health insurance for myself and any dependents though the Federally-Facilitated Marketplace ("FFM"), including, but not limited to the following actions:
Select a health plan for me;
Apply for and enroll me (and any dependents) in the selected health plan;
Add or remove coverage;
Create or change a beneficiary or dependent designation;
Update contact information for me and any dependents or beneficiaries;
Update information relevant to eligibility for subsidies for the health insurance;
Submit supplemental materials to a health insurance marketplace or exchange, including, but not limited to, proof of income and social security numbers;
Keep my health insurance in-force by renewing coverage from time to time;
Change the health plan at renewal if a better plan is available; and
Take any other action with regard to such health insurance as permitted by law.
The authority granted to Health Care Market Quotes hereunder will cease upon my death, incapacity, or if I revoke the power of attorney in writing to Health Care Market Quotes
Any person, including, without limitation, Health Care Market Quotes, any web-broker through which Health Care Market Quotes may submit an application for insurance on my behalf, and the FFM, may rely upon the validity of this limited power of attorney or a copy of it unless that person knows it has been terminated.
By checking this box I provide my express consent to Health Care Market Quotes and grant Health Care Market Quotes and/or its agents a limited power of attorney to enroll me in a health insurance plan and to automatically enroll me in a plan at renewal.
I hereby signify my agreement with the foregoing by signing below *