Healthcare.gov

Authorization for Registered Agent/Broker

Authorized Representative with Healthcare.gov

Please call the Marketplace and tell them you want to authorize your Insurance Agent: Maria Lopez Agent # 7545454, to be your authorized representative for 365 days with no limits. Please write down the name of othe representative here and the date and time you spoke.

Marketplace Phone: (800)318-2596 Available 24/7 Estan disponibles 24/7

Por favor de hablar al Mercado de Salud para renovar la autorizacion. Digales que quiere autorizar a su agente: Maria Lopez #7545454 para que sea su representante por 365 dias sin limites. Por favor escria el nombre del representante aqui y tambien el día y la fecha que hablo.

Write down your name, phone number and the name of the representative you spoke to give consent for us to work on your account/ Por favor escriba su nombre & Telefono y el hombre del representate con el que dio consentimiento.