Privacy Notice and PII Consumer Consent

As required by Centers for Medicare and Medicaid Services (CMS) and the Individual Marketplace and SHOP Privacy & Security Agreements that all agents and brokers must submit a privacy notice to ensure openness and transparency about policies, procedures, and technologies that directly affect consumers’ PII. PII is any information that can be used to distinguish or trace a consumer’s identity (e.g., his or her name, Social Security Number, biometric records) alone or when combined with other personal or identifying information that is linked or linkable to a specific consumer (e.g., date of birth, place of birth, mother’s maiden name).

Filling out this form will give the listed Utah Avenue Insurance Licensed Agent and all Utah Avenue Insurance staff members legal authority to collect your PII for purpose of data verification to submit potential applications to Insurance Carriers through the Marketplace Enhanced Direct Enrollment (EDE) platform and third party platforms in an attempt to gain an insurance policy or limited benefits.

This PII information will be disclosed to applicable Insurance Carriers, Utah Avenue Insurance’s third party technology affiliates, any Utah Avenue Insurance support staff in an effort for processing applications, client supports, Utah Avenue Insurance marketing system, email campaigns, texting campaigns, and other similar uses and platforms as outline by Utah Avenue Insurance now or with future changes and applications in technology.

This request for PII from you is voluntary and not required by law. At any point you may request a copy of your PII information provided in this form which will be provided to you in the most timely manner possible given the time of year demand, or other factors outside of our control.

You are hereby giving permission to:

1) conduct an online "person" search through the marketplace to obtain an existing application,
2) assist with completing an eligibility application,
3) assist with plan selection and enrollment, and
4) assist with ongoing account/enrollment maintenance.

This will include your application for plan year 2024 health insurance as well as any subsequent years in the future until such permission is terminated in writing sent to the address listed for the authorized Agent below.

This notice also serves as a Record of Consumer Consent and is subject to your right of withdrawal. By signing or submitting this form you are agreeing to the outline above as well as all other terms and conditions listed in this form.

2024 & 2025 Advance Premium Tax Credit Disclosure

I understand that I will lose my premium tax credit if I'm found eligible for other minimum essential coverage, like coverage through my job or Medicare. I also understand that if I don't contact the Marketplace about my eligibility for other coverage, I will lose my coverage through the Marketplace.

Further, I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents for plans with 2024 effective dates:

I must file a federal income tax return in 2025 for the tax year 2024.
If I'm married at the end of 2024, I must file a joint income tax return with my spouse. I also expect that:
No one else will be able to claim me as a dependent on their 2024 federal income tax return.
I'll claim a personal exemption deduction on my 2024 federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through this Marketplace and whose premium for coverage is paid in whole or in part by advance payments.

Further, I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents for plans with 2025 effective dates:

I must file a federal income tax return in 2026 for the tax year 2025.
If I'm married at the end of 2025, I must file a joint income tax return with my spouse. I also expect that:
No one else will be able to claim me as a dependent on their 2025 federal income tax return.
I'll claim a personal exemption deduction on my 2025 federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through this Marketplace and whose premium for coverage is paid in whole or in part by advance payments.

If any of the above changes, I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2024 and 2025 federal income tax returns, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

Terms, Conditions and Disclosure of Information

As the Primary Applicant listed on this Questionnaire, I hereby understand that by signing this Questionnaire I verify and/or agree that the information given is true and correct to the best of my knowledge and belief. I further understand that this questionnaire, and the information listed herein, constitutes a basic gathering of information intended for Utah Avenue Insurance and its affiliated agents to better understand my specific health benefit needs (including benefits through the Health Insurance Marketplace) and for entry in a health benefit plan application, and IS NOT an official application for a qualified health plan.

I acknowledge that all options and benefits of each health benefit package were explained to me in detail by Utah Avenue Insurance and/or its affiliated agents, including, but not limited to, the Utah Avenue Insurance agent listed in the authorization section of this form (“my Compass Agent”) regarding, but not limited to, insurance coverage, insurance carriers, and network providers. I also acknowledge that this is a Privacy Notice Statement in an attempt to collect Personal Identifiable Information (PII) that may be used for any qualified or non-qualified insurance benefits.

I also agree and acknowledge that I was shown health benefit coverage options that meet the minimum essential coverage as outlined under the Affordable Care Act, and thereby indemnify and hold Utah Avenue Insurance and/or my Utah Avenue Insurance Agent harmless from any liability relating to the health benefit package I choose to enroll in and for the benefits ultimately received from such health benefit package.

I further acknowledge that if I choose a non-qualified benefit package, such as, but not limited to, a short-term medical plan or limited benefit or discount plan, I understand that it does not meet the minimum essential coverage as outlined under the Affordable Care Act. I also understand that if I select a non-qualified benefit package that does not meet the minimum essential coverage as outlined under the Affordable Care Act, the resulting consequence can include, but is not limited to, any and all tax sharing, tax shared responsibility, tax penalty or any otherwise incurred penalties as carried out by the IRS relating to the Affordable Care Act. I acknowledge that the advantages and disadvantages of selecting a non-qualified benefit package have been clearly explained to me by Utah Avenue Insurance, its affiliated agents, and/or my Utah Avenue Insurance Agent.

I hereby agree to indemnify and hold harmless Utah Avenue Insurance, its employees, agents and/or my Utah Avenue Insurance Agent from and against any and all actions, claims, lawsuits, demands, costs, expenses, liabilities and losses, including reasonable attorney’s fees (“Claims”), which may result against me by reason of any acts or omissions of Utah Avenue Insurance, its agents, employees, or my Utah Avenue Insurance Agent in connection with, but not limited to, the benefits received from my selected health benefit package, the loss and/or mishandling of information listed in this Questionnaire, and/or any tax implications known or unknown relating to the benefit package I select for enrollment. I acknowledge that in order to fully understand any and all tax implications deriving from the benefit package I select, it is my responsibility to speak with a qualified tax attorney and/or accountant.

By signing this acknowledgment, I hereby authorize Utah Avenue Insurance, its affiliated agents, and/or my Utah Avenue Insurance Agent to enter any and/or all information contained in this Questionnaire in any and/or all applicable online application(s) of the insurance carrier(s) for the health benefit plan selected by me as an appropriate and potential health benefit option for myself as the Primary Applicant and for any applicable Spouse Applicant and/or Dependent Applicant(s) for all benefits included in this enrollment; this also includes entering information on healthcare.gov for purposes of, but not limited to, creating an account on my behalf and on behalf of any Spouse Applicant and/or Dependant Applicant(s) listed by me as the Primary Applicant in this Questionnaire.

Further, by signing this Questionnaire, I unreservedly authorize my Utah Avenue Insurance Agent, and/or any other Utah Avenue Insurance agent and/or employee (“Employee”), full and complete access to the information entered and/or disclosed on this Questionnaire. This authorization includes, but is not limited to, the ability for any Utah Avenue Insurance Employee to utilize this information and enter such information onto any websites requiring such information for health benefit application, enrollment and/or benefit information purposes. I further authorize my Utah Avenue Insurance Agent to electronically sign any such online health benefit application(s) on my behalf and agree that such electronic signature possess the same legal significance as if I personally and/or electronically signed the application myself.

Marketplace Representation

Marketplace Representation Authorization

Assistance with completing your marketplace application

For certified application counselors, navigators, agents, and brokers only

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling the application for somebody else.

Agent: Spencer Ellis
Utah Avenue Insurance
Agent NPN:

You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change or remove your authorized representative, contact the Marketplace. If you’re a legally appointed representative for someone on their application, submit proof with the application.

Authorized Representative: Spencer Ellis

Utah Avenue Insurance
910 E 100 N, Ste 105, Payson UT 84651
(801) 609-8699

By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters related to this application.

Agent of Record Letter

To Whom It May Concern:

I hereby designate Spencer Ellis as Agent of Record, effective with respect to the medical and/or dental insurance product(s) purchased from the company.

In making this designation, I authorize my Agent of Record to access information about my insurance products and represent me to facilitate the ongoing service of my product(s).

I understand that adding or changing the Agent of Record does not change the premium of my product(s) and is included as part of my policy at no additional cost. Any compensation from the company payable to an agent should be directed to:

Spencer Ellis

801-609-8699

office@utahavenue.com

910 E 100 N, Ste 105, Payson, UT 84651

This Agent of Record Letter rescinds any prior appointments of agent/agency with respect to this coverage and shall remain in effect until revoked or replaced in writing. I understand the company will notify the current agent of this change.

I understand that the terms and conditions of this appointment will be subject to the company's specific contractual requirements, as well as the normal agent appointment procedures.

I understand that the company may contact me to validate the authenticity of this letter. I have provided my phone number and email.

The Agent of Record shown above hereby accepts the designation set forth above and confirms the representations made herein.

Scope of Appointment

Scope of Appointment Confirmation Form

Medicare requires Licensed Sales Representatives to document the scope of an appointment prior to any sales meeting to ensure understanding of what will be discussed between them and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential. A separate form should be completed for each Medicare beneficiary.

To ensure your appointment focuses only on those Medicare and health-related products you want to discuss with your licensed sales representative, please indicate by checking the appropriate box(es) beside the product(s) in which you are interested.

x Stand-alone Medicare Prescription Drug Plans
x Medicare Advantage Plans (Part C) and Cost (Pard D) Plans
x Dental/Vision/Hearing Products
x Hospital Indemnity Products
x Medicare Supplement or (Medigap) Products

By signing this form, you agree to a meeting with a Licensed Sales Representative to discuss the types of products you checked above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the federal government. This individual may also be paid based on your enrollment in a plan.

Signing this form does NOT obligate you to enroll in a plan, affect your current or future Medicare enrollment, or enroll you in a Medicare plan.

To be completed by Licensed Sales Representative
Licensed Sales Representative Name: Spencer Ellis

Phone: 801-609-8699
Licensed Sales Representative ID:
Beneficiary Name:
Beneficiary Phone:
Date appointment will be completed:
Initial method of contact:
Plans the Licensed Sales Representative will represent during the meeting:
Licensed Sales Representave Signature:

Scope of appointment (SOA) is subject to Medicare Record Retention Requirements.
Licensed Sales Representative: If applicable, please explain why SOA was not documented and signed by beneficiary prior to meeting. Check all that apply.

Unplanned Attendee
New SOA required (consumer requested other Health Product information)
Walk-in
Other (please explain)

Primary Applicant Name *

Date * +

Primary Signature *

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