I, (Primary Houshold Contact and/or Authorized Representative) give my permission to Anthony Insurance Group and any of their agents/brokers to serve as the health insurance agent/broker/agency for myself and my entire household if applicable, for purposes of enrollment in a Health Plan offered on the Federally Facilitated Marketplace, state based exchange or directly with the carrier. By consenting to this agreement, I authorize the above-mentioned Agent/Broker/Agency to view and use the confidential information provided by me in writing, electronically, by telephone or text only for the purposes of one or more of the following:

• Searching for an existing Marketplace or state-based exchange application

• Completing an application for eligibility and enrollment in a Marketplace or state-based exchange

• Qualified Health Plan or other government insurance affordability programs, such as Medicaid, CHIP, or advance premium tax credits (APTC) to help pay for Marketplace or state-based exchange premiums or enrollment directly with a carrier.

• Providing ongoing account maintenance and enrollment assistance.

• Responding to inquiries from the Marketplace, state-based exchange or insurance carrier regarding my Marketplace, state-based exchange, or direct application.

I understand that the Agent/Broker/Agency will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent/Broker/Agency will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provide for entry on my Marketplace, state-based exchange or direct enrollment eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent/Broker/Agency beyond what is required on the application for eligibility and enrollment purposes. In addition, I agree not to hold the agent/broker/agency accountable should I give incorrect information regarding my income and owe back any of the APTC that I was not eligible for. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time in writing either by email or USPS to Anthony Insurance Group, 6126 W State St, Boise ID 83703. Telephone/text is not an acceptable procedure for cancelation.

Name of Primary Writing Agent: Stacie Anthony

Agent National Producer Number: 16982552

Name of Agency: Anthony Insurance Group, LLC

Agency National Producer Number: 18374249

Owner of Agency: Stacie Anthony

Phone Number: (208) 295-0067 Email Address:

stacie@aigidaho.com