ACA Constent Form

Name(Required)

First Last

I give my permission to my agent, Jon Nolan, to serve as the health insurance agent or 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 the above-mentioned Agent 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
Responding to inquiries from the Marketplace regarding my Marketplace application

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent 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 an Agent 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 contacting my Agent.

Name of Writing Agent: Jon Nolan
Agent National Producer Number: 17530407
Phone Number: 817-521-6777
Email Address: jon@jonnolaninsurance.com

Authorized Representative (if any)(Required)

Type NONE or N/A if there is no Authorized Representative

Name of Primary Household Member(Required)

Email Address(Required)

Phone Number(Required)

Signature(Required)

Date(Required)

* If listing Authorized Representative, all contact information and Signature must belong to that person. However, Name of Primary Household Member must also be listed on the line above.

Comments

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Jon Nolan Insurance

We extend coverage to individuals and businesses in 4100 Alpha Rd Suite 472 Dallas, TX 75244 and surrounding areas.

Phone: (469) 205-6888

Email: jon@jonnolaninsurance.com

Office Hours:
Monday to Friday: 8 am to 5 pm
After hours:
Saturday & Sunday - By phone or appointment

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Medicare

Health Insurance

Life Insurance

Supplemental Insurance

Know More

Jon Nolan Insurance offers a wide range of insurance plans across Texas, including Medicare Supplement (Medigap), Medicare Advantage (Part C), Prescription Drug Plans (Part D), individual and group health insurance, life insurance, as well as dental and vision coverage. We proudly serve cities like Dallas, Fort Worth, Arlington, Plano, Frisco, Denton, McKinney, Irving, Garland, Coppell, and Rockwall—covering counties including Dallas, Tarrant, Collin, Denton, Ellis, Johnson, Kaufman, Parker, and Rockwall.
Not affiliated with or endorsed by the U.S. government or the federal Medicare program.