Filling out this form means that you are applying to allow Xtreme Insurance, it's principal owner Tony Cooke, a licensed agent in SC, NC, and GA, and also certified through CMS to handle both individual and shop plans through the Marketplace, permission to serve as the health insurance agent or broker for either your self or your entire household if applicable, for the purpose of enrollment in a qualified heath plan offered under the The Federally Facilitated Marketplace. By consenting to this agreement , I authorize Xtreme Insurance and Tony Cooke to view and use the confidential information provided by me in writing, electronically, or by telephone for the purpose of one or more of the following
searching for an existing Marketplace application
Completing an application for eligibility and enrollment in a Marketplace Health Plan or other government insurance affordability program such as Medicaid and CHIP, or advance tax credits to help me pay for Marketplace Premiums.
Providing ongoing account maintenance and enrollment assistance, as necessary, or
Responding to inquiries from the Marketplace regarding my Marketplace application and enrollment.
I further understand that Xtreme Insurance and Tony Cooke will not share or sell my information, other than through our enrollment platform Healthsherpa, which is connected to the Marketplace and to the carrier that I have selected. The information provided is used for the purpose of applying, updating or maintaining my account, though I may get emails or phone calls from time to time regarding use of the health plan selected or other lines of business offered by Xtreme and or Tony Cooke only. I will contact the above mentioned if I feel there has been a violation of this by any other party.
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 this enrollment remains in effect until I revoke it, and may revoke or modify my consent at anytime by Contacting:
Xtreme Insurance Tony Cooke NPN 18809400
845-594-6572 or 843-999-0124
or in writing and mailed to
2764 Pleasant Rd Suite A PMB 10632
Fort Mill, SC 29708
