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By signing, I grant permission to act on my behalf and that of my entire household in matters related to enrollment in a Qualified Health Plan via the Federally Facilitated Marketplace. This authorization also extends to any authorized representative or power of attorney acting on my behalf. The agents empowered by this agreement are Peace Tree Insurance LLC and/or its affiliates. These agents are authorized to locate existing Marketplace applications, complete applications for eligibility in various plans and programs, provide necessary ongoing maintenance, and respond to inquiries about my application from the Marketplace. I understand and agree that my personally identifiable information will be accessed and used solely for the objectives specified in this document. I attest that all the details I provide for the purposes of eligibility and enrollment will be accurate to the best of my ability. I am under no obligation to disclose additional personal or health-related information beyond what is required for these applications. My consent remains effective until I choose to revoke it. For any modifications or to revoke this consent, I can email help@peacetreeinsurance.com or calling (833) 303-707

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First Name

%first-name%

Applicant Date of Birth

%mm-dd-YYYY%

Last Name

%Last-name%

Gender

%gender%

Marital Status

%marital status%

Phone

%Phone%

Email

%Email%

Address

%Address%

City

%City%

State

%state%

Zip Code

%zipcode%

Review Your Application

Spouse Name

%spouse full name%

Spouse DOB

%spouse DOB%

Spouse Gender

%spouse gender%

Spouse SSN

%spouse SSN%

Dependant 1 Name

%dependent-1-name%

Dependent-1-gender

%dependent-1-gender%

Dependent-1-DOB

%dependent-1-DOB%

Dependent-1-relationship

%dependent-1-relationship%

Review Your Application

Household Income

%householdincome%

Monthly or Yearly

%monthly-yearly%

$0 Plan Option

%plan-option%

Income Verification

%income-verification% ( I Agree)

Consent to Enrollment

%Consent-to-Enrollment% ( I Agree)

Authorization and Tax attestation

%Authorization-Taxattestation% (I Agree)

Permission to Peace Tree Insurance LLC

%permissionPeaceTreeInsurance% (YES)

Do you have insurance through your employer, Medicare, Medicaid or VA?

%Do you have insurance through your employer, Medicare, Medicaid or VA? %

Consent Acknowledgement

%Consent Acknowledgement %

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