Agent & Broker & Consumer Responsibility - Healthcare Enrollment

Agent and Broker Responsibilities * Consumer Responsibilities * Consent to Access PII
Silva Insurance Services, LLC is appointed as agent or broker. The services include assisting with enrollment through The Marketplace and the placement and processing of insurance policies and other insurance related services mutually agreed upon.
Agent and Broker Responsibilities
We will provide information in a fair, accurate and impartial manner.
We will advise if any conflict of interest is applicable.
We do not accept direct payments or provide gifts.
We will not contact you will unsolicited direct contact including robo-calls.
We do not discriminate and accommodate by providing culturally and linguistically approved services and services accessible to those with disabilities.
We are not acting as a tax advisor or attorney when providing assistance as an agent or broker, and cannot provide tax or legal advice within our capacity as a agent or broker.
PII is information that can be used to distinguish or trace an individual’s identity, such as their name, social security number, biometric records, alone, or when combined with other personal or identifying information that is linked or linkable to specific individual, such as date of birth, or others maiden name.
Agents and brokers follow privacy and security standards to protect consumers PII. Agents and brokers may access consumers PII, such as names, dates of birth, financial information or social security numbers when carrying out authorized functions.
We take precautions while handling consumers PII to protect the confidentially of the information. We adhere to the attached notice of privacy practices.
Consumer Responsibilities
Consumers must provide complete and accurate information on the marketplace eligibility application.
Consumers must accurately report all required sources and amounts of income.
Consumers should not ask agent or brokers to misrepresent consumers’ information while apply for health coverage.
Consumers must notify the Marketplace of any inaccurate information included on their eligibly application.
Consumer Consent
The consumer understands the functions and responsibilities that apply to the agent broker role.
The consumer consents for agent broker to access and use the consumer’s PII to carry out authorized functions.
The consumer may revoke any part of the authorization at any time, as well as a description of any limitations that the consumer wants in place on your access or use of the consumers PII.
The consumer is not required to provide any PII.
The help agents and brokers can provides is based only on the information the consumer provides, and if the information given is inaccurate or incomplete, we may not be able to offer all the help that is available for the consumers situation.
We will only ask for the minimum amount of PII to carry out our functions and agent or broker.
Any Limitations on scope of authorization: ______________________________________
Signed Acceptance: ______________________________________ Date: __________
Print Consumer Name:______________________________________
Verbal Acceptance: ______________________________________ Date: __________
Agent/Broker Name: __Dusty Silva__________________________Silva Insurance Services, LLC

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