I, Mr. Mrs.. , I hereby request and authorize MILEIBI MARGARITA LEON to enroll me in health insurance through the Health Insurance Marketplace. I have provided the necessary information to qualify for the tax credit offered by the Health Insurance Marketplace and thus obtain the benefits of a reduced premium.

I hereby authorize the agent and entities specified above to act as my health insurance agent or broker, and for my entire family, if applicable. By agreeing to this arrangement, I authorize the viewing and use of the confidential information I have provided in writing, electronically, or by telephone, solely for one or more of the following purposes:

1. Conducting a search and/or creating an application on the Health Insurance Marketplace;

2. Completing an eligibility application and enrollment in a Qualified Health Plan on the Marketplace, including plan selection, applications, initial payments, and uploading required documents.

3. To provide ongoing account maintenance and enrollment assistance, as needed, in response to life changes such as my address, household information, income, or any other information that may affect my coverage.

4. I authorize my agent to contact me via text message, email, phone, or any other means necessary to inform me about services related to my insurance marketplace application.

I understand that my consent remains in effect until I revoke it, and I can revoke or modify my consent at any time by contacting my agent to receive notification that the consent has been revoked.

I also understand that if any changes occur to the information provided below and/or other information, I must inform you immediately so that my application can be updated.

Marital status:

Projected annual family income:

Number of people on your tax return:

People with medical coverage:

I confirm that I do not have any other health insurance, nor do I have a job offer for health coverage.

I sign this consent under penalty of perjury, meaning that I have provided truthful answers to all questions to the best of my knowledge and belief. I understand that I may be subject to penalties under federal law if I intentionally provide false information.

NOTE: THIS CONSENT IS VALID DURING THE 2026 REGISTRATION PERIOD.