1095 A Form

First Name (required)

Last Name (required)

Date of Birth (required)

Email (required)

Zip (required)

Phone (required)

YES! I agree to the consent. Please help me with my Marketplace Account.

Georgia Consent form to assist with Marketplace Health Insurance Plan
Yes, I understand by checking below I will allow access to my Marketplace Account. I will be emailed my 1095A and will obtain FREE assistance with reviewing plan information, updating address, updating income, and help maintaining my Marketplace Health Insurance account. Agent can also assist during renewal and anytime information needs updated. In the event my income or household tax filing changes, it is my duty to contact my agent or the Marketplace in a timely manner. I give sole permission to designated FFM Certified agent NPN 17847616 Dan Rhoads to create, collect, disclose, access, maintain, store, and/or use my Personally Identifiable Information (PII) needed to carry out the roles and responsibilities of a licensed insurance agent and act on my behalf and obtain 1095A for me. Agent can conduct a search for my consumer application through the Marketplace and be listed as agent of record on the policy. Agent can also assist with completing an eligibility application, assist with plan selection and enrollment, assist with ongoing account / enrollment maintenance. I understand this service is FREE to me as a legal resident of the United States.