I authorize Health Benefits Enrollment Center and Its agents to assist me with my Health Insurance Marketplace application and to access, search for, review, and use my Marketplace application information for the purpose of assisting me with my Marketplace eligibility and enrollment.

I understand that I am providing this authorization voluntarily and that I may obtain Marketplace assistance from another source.

By selecting the checkbox below and entering my legal name, I consent to using an electronic signature for this form and understand that my electronic signature is intended to have the same legal effect as my handwritten signature, to the extent permitted by applicable law.

I confirm that I am signing this form voluntarily and that the information I have provided is true and accurate to the best of my knowledge.