Client Consent Agreement

This Client Consent Agreement is between Gifford Insurance (hereafter “Broker”) and Client (named below) and represents an¬†agreement for Broker to act on Client’s behalf within the scope of responsibility detailed below.

Broker Responsibilities

a. represent Client’s interests when quoting, applying for coverage and/or tax credits, creating accounts (including on healthcare.gov), enrolling in plans/programs, working with insurance carriers, the Marketplace, and related entities

b. provide information in a timely, fair, accurate, and impartial manner

c. disclose any conflict of interests

d. NOT provide tax or legal advice within capacity as a broker

e. collect, use, and share Client’s Personally Identifiable Information (PII) within the scope of broker’s role

f. protect Client’s PII from unauthorized use, loss and/or theft

g. recieve compensation from carriers and/or third-parties for services rendered or placement of insurance

Client Responsibilities

a. provide Broker with complete and accurate information

b. have consent from all insured individuals to disclose their personal information

c. not ask Broker to misrepresent Client

d. notify Broker of any changes or inaccurate information

e. reconcile Premium Tax Credits with the IRS

Client Consent Agreement

I agree that …

a. I understand the Broker Responsibilities section above

b. I understand the Client Responsibilities section above

c. I understand that providing PII is voluntary

d. I may revoke or limit any part of this consent at any time

e. I understand that help Broker provides is based on the information I provide, and if the information I provide is

inaccurate or incomplete, Broker may not be able to accurately present options or offer all the help that is available

f. I authorize Broker and/or their authorized representatives to quote, apply, enroll and provide services on my behalf

g. I (if applicable) understand that Advance Premium Tax Credits (APTC) will be paid directly to my health insurance carrier and are based on my reported tax-filing status, county of residence, tax household size, and projected income and that I will reconcile my APTC with the IRS based on ACTUAL tax-filing status, county of residence, tax household size and income, which may require me paying back some or all of the APTC

Complete one section below indicating consent to the above agreement

Verbal Consent
Electronic Consent
Electronic Signature

*Note: Brokers are federally required to store consumer consent forms for at least six years