Phone: (757) 461-0519

Consent Form

Thank you for the confidence you have placed in our agency to assist you with your insurance needs. We are providing you with a copy of this consent notification so you fully understand the scope of the assistance we will render and ask you to acknowledge receipt and consent to proceed. Please Read This Page and Complete The Below Consent Form.

As your broker, we may collect, disclose, assess, maintain and/or store personal information. This information is protected as outlined in our Privacy Statement.

Your information may be used to perform the following:

    1. Assist with plan comparisons and selection.
    2. Assist with applications for eligibility with insurance carriers we represent and may also include the Federally Facilitated Marketplace (FFM).
    3. Regarding FFM eligibility:
      a. Assist with application for receipt of advance payments of the premium tax credit (APTC) or cost-sharing reduction (CSR) and selecting APTC amount, if applicable to your situation.
      b. Facilitate the collection of standardized attestations acknowledging the receipt of the APTC or CSR determination, if applicable.
      c. Assist with the application for and determination of certificates of exemption.
      d. Assist with filing appeals of eligibility determinations in connection with the FFM.
    4. Submit on behalf of applicant, application for insurance electronically or by paper application.
    5. Facilitate payment of the initial premium amount on behalf of the applicant.
    6. Facilitate an enrollee’s ability to dis-enroll.
    7. Educate consumers, applicants and enrollees on insurance affordability programs.
    8. Assist an enrollee’s ability to report changes in eligibility status throughout the plan year.
    9. Correct errors on the behalf of the applicant/enrollee.
    10. Contact insurance carrier on the behalf of the enrolled to render assistance with policy.

We value you as a customer. Thank you for choosing Benefit Plans Inc.