Kral Insurance Group LLC- ACA Consent Form
Sign in to Google to save your progress. Learn more
Affordable Care Act Marketplace Enrollment Consent Form
I give my permission to Casey Kral, Trisha Kral and Kral Insurance Group LLC 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: 

1. Searching for an existing Marketplace application; 

2. 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; 

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

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

I understand that if I choose a plan through a carrier on the Marketplace that my agent is not contracted with that my agent can still assist me with enrollment, but that I will be considered a referral to Health Sherpa and give my consent for them to help manage my account as needed.

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 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 emailing Casey Kral at casey@kralinsurancegroup.com with a written request.

Name of Primary Writing Agent:   Casey Kral, Trisha Kral or Kral Insurance Group LLC
Agent National Producer Number:  18735765; 20103959
Agency NPN: 20720661
Phone Number: 682-333-0102
Email Address: casey@kralinsurancegroup.com

Name of Primary Household Contact and/or Authorized Representative *
Phone Number *
Email Address *
Terms and Conditions: You AGREE to only provide truthful and accurate information to the best of your ability and to hold harmless and defend all parties from any claims, actions, liabilities, suits, injuries, demands, obligations, losses, settlements, judgments, damages, fines, penalties, costs and expenses arising out of any false or inaccurate information you provide. 

By clicking "I Agree" you (1) acknowledge that you have read, understood and agreed to all of the above statements and (2) are giving Casey Kral, a licensed agent, and/or Kral Insurance Group LLC, his licensed agency, CONSENT to assist and enroll you with your Marketplace coverage. *
Please type your name below to act as your signature.
 *
Today's Date *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Kral Insurance Group.

Does this form look suspicious? Report

Google Forms