New regulations were implemented in June of 2023 requiring that individuals provide their consent when working with an insurance professional to secure individual coverage for Affordable Care Act (ACA) plans. Please call/text David Flores at 847-849-0564 for a Passcode. Please submit the form below so that we may begin working together. You will enter the Passcode on the form as a means of validating your identity.

I, the Primary Household Contact listed below, give my permission to David Flores to serve as the health insurance broker for myself and my entire household, if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize David Flores to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

• Searching for an existing Marketplace application;

• Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums;

• Providing ongoing account maintenance and enrollment assistance, as necessary; or

• Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that David Flores will not use or share my personally identifiable information (PII) for any purposes other than those listed above. David Flores 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 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 David Flores beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by written notice, email, or phone call.

Broker Name: David Flores, Founder & CEO

Agency Name: Cotinuum, LLC

National Producer Number: 2120099

Phone: 847-849-0564

Email: dflores@cotinuum.com