Name of Primary Writing Agency/Agent: Kairos Solution Inc / Kay K Bo

Agency/Agent NPN:19807324/ 18788424

Agency/Agent Phone Number: (646) 309 1252

Email Address: insurance@kairoxsolutionagency.com

to serve as the health insurance broker/agent for purposes of enrollment assistance in the Health

By consenting to this agreement, I authorize the above-mentioned Agent/Agency/Employee of the Broker/Agent to view and use the confidential information provided by me in writing, e- mail or by telephone only for the purposes of one or more of the following:

By consenting to this agreement, I authorize the above-mentioned Agent/Agency/Employee of the Broker/Agent to view and use the confidential information provided by me in writing, e- mail or by telephone only for the purposes of one or more of the following:

1. Searching for an existing Marketplace application;
2. Assist with application, eligibility, plan selection, enrlilment, renewal, and disenrollment activities.
3. Assist consumers with applying for APTC and CSR eligibility determinations. Educate consumers on Insurance Affordability Programs, Medicaid, and the Children’s Health Insurance Program (CHIP), if applicable
4. Providing ongoing account maintenance and enrollment assistance, as necessary; or
5. Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that only authorized personnel will use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agency/Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

confirm that the information I provided for entry on my Marketplace eligibility and enrollment application is accurate and 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 my 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 sending an email to insurance@kairoxsolutionagency.com.