By Completing this form, I give my permission to Kirk Lewis (NPN 11464507) with Quality Employee Benefits Agency (423-499-2962) / klewisins@gmail.com to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Georgia State-based Exchange (Georgia Access). By consenting to this agreement, I authorize the above-mentioned agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: 1) I give permission to access my information for the purpose of helping me complete an application for eligibility and enrollment in a Qualified Health Plan or other insurance affordability programs, such as Medicaid and PeachCare for Kids (CHIP) or advance tax credits to help pay for insurance premiums. 2) I agree that I have been informed and agree with all the disclaimers included in my exchange application. 3) I understand the plan(s) I am being enrolled in and agree that I wish to be enrolled in that plan; I understand that I may cancel the delegation at any time either within the Georgia Access portal, a certified partner portal, or by calling the Georgia Access contact center at 1-888-687-1503. 4) I give the agent and any member of their agency permission to assist me in maintaining my information and changing my plans in the future without requiring consent. I understand that I am not obligated to provide this consent, but if I do not, I will need to document a new consent every time I require future assistance from my agent.

I agree

By completing the below information, this will serve as my electronic signature for consent to the above for the purpose of enrollment in a Qualified Health Plan offered on the Marketplace.

First Name

Last Name

Phone

(###)

###

####

Date

Consent begins on the below date and remains in effect until I revoke it.

YYYY