YOUR AUTHORIZATION IS REQUIRED BY LAW

Before we are allowed to assist you with your insurance needs, we will first need your written authorization to do so. Please review this important information about your rights and protections under the law before agreeing to the terms.

I authorize Tracy Cornett - Cornett Consulting (and its affiliates) to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of quoting and enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize Tracy Cornett - Cornett Consulting (and it's affiliates) 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. 3. Enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP. 4. To apply for advance tax credits to help pay for Marketplace premiums. 5. Providing ongoing account maintenance and enrollment assistance, as necessary. 6. Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. Tracy Cornett - Cornett Consulting (and it's affiliates) 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 in writing by sending an email to: tcornett@healthmarkets.com.

PLEASE SIGN AND DATE YOUR AUTHORIZATION

ENTER YOUR FULL NAME HERE *

TODAY'S DATE *

Primary Member Profile

First Name *

Last Name *

Date of birth *

Gender *

Phone *

Email *

Street Address

City

State

Zip Code *

County *

Primary Member Health History

Do You Use Nicotine Products?

Height Feet

Height Inches

Weight in lbs

Medications

Preferred Providers

Diagnosis

Additional Comments

Primary Member Employer and Income Information

Primary Member Employer

Primary Occupation

Primary Annual Income

This is the amount you expect to pay taxes on for the year you're applying for coverage. If unsure, start with an approximate or look at your tax return from last year to get an idea. We're needing your "modified adjusted gross income" (AGI).

If Yes, Select Box

I Have Access To Other Coverage But Declined The Coverage (didn't like or too expensive)

I Have Access To Other Coverage But I'm Waiting For Enrollment Period

I Qualify For Medicaid, TriCare Or Tribal Coverage

Are you married or will you be married by the time your coverage starts? *

Spouse Information

Spouses First Name

Spouses Last Name

Spouses Phone Number

Spouses Email

Spouses Date of Birth

Spouses Gender

Spouses Occupation

Spouses Employer

Spouses Annual Income

Spouse If Yes, Select Box

My Spouse Has Coverage Available Elsewhere But Declined Coverage (didn't like or too expensive)

My Spouse Has Coverage Available Elsewhere But Is Waiting For Enrollment Period

My Spouse Qualifies For Medicaid, TriCare Or Tribal Coverage

My Spouse Uses Nicotine Products

Spouse Height Feet

Spouse Height Inches

Spouse Weight (lbs)

Spouse Providers, Diagnosis and RX

Spouse Additional Notes

Do you need to add dependents to your household or coverage?

Yes

Dependent 1 Information

D1 Full Name

D1 Date of Birth

D1 Gender

D1 Annual Income and Source

D1 Providers, Diagnosis and RX

D1-If Yes, Select Box

This Member Will Be Claimed On My Taxes For The Coverage Year

This Member Needs To Be Added To My Coverage

This Member Has Coverage Available Elsewhere But Declined The Coverage (didn't like or too expensive)

This Member Has Coverage Available Elsewhere But Waiting For Enrollment Period

This Member Qualifies For Medicare, Medicaid, TriCare Or Tribal Coverage

This Member Uses Nicotine Products

D1 Additional Comments

Add Dependent 2 *

Yes

Dependent 2 Information

D2 Full Name

D2 Date of Birth

D2 Gender

D2 Providers, Diagnosis and RX

D2 Annual Income and Source

D2- If Yes, Select Box

This Member Will Be Claimed On My Taxes For The Coverage Year

This Member Needs To Be Added To My Coverage

This Member Has Coverage Available Elsewhere But Declined The Coverage (didn't like or too expensive)

This Member Has Coverage Available Elsewhere But Is Waiting For Enrollment Period

This Member Qualifies For Medicare, Medicaid, TriCare Or Tribal Coverage

This Member Uses Nicotine Products

D2 Additional Comments

Add Dependent 3 *

Yes

Dependent 3 Information

D3 Full Name

D3 Date of Birth

D3 Gender

D3 Providers, Diagnosis and RX

D3 Annual Income and Source

D3-If Yes, Select Box

This Member Will Be Claimed On My Taxes For The Coverage Year

This Member Needs To Be Added To My Coverage

This Member Has Coverage Available Elsewhere But Declined The Coverage (didn't like or too expensive)

This Member Has Coverage Available Elsewhere But Is Waiting For Enrollment Period

This Member Qualifies For Medicare, Medicaid, TriCare Or Tribal Coverage

This Member Uses Nicotine Products

D3 Additional Comments

Add Dependent 4 *

Yes

Dependent 4 Information

D4 Full Name

D4 Date of Birth

D4 Gender

D4 Providers, Diagnosis and RX

D4 Annual Income and Source

D4-If Yes, Select Box

This Member Will Be Claimed On My Taxes For The Coverage Year

This Member Needs To Be Added To My Coverage

This Member Has Coverage Available Elsewhere But Declined The Coverage (didn't like or too expensive)

This Member Has Coverage Available Elsewhere But Is Waiting For Enrollment Period

This Member Qualifies For Medicare, Medicaid, TriCare Or Tribal Coverage

This Member Uses Nicotine Products

D4 Additional Comments

Add Dependent 5 *

Yes

Dependent 5 Information

D5 Full Name

D5 Date of Birth

D5 Gender

D5 Providers, Diagnosis and RX

D5 Annual Income and Source

D5-If Yes, Select Box

This Member Will Be Claimed On My Taxes For The Coverage Year

This Member Needs To Be Added To My Coverage

This Member Has Coverage Available Elsewhere But Declined The Coverage (didn't like or too expensive)

This Member Has Coverage Available Elsewhere But Is Waiting For Enrollment Period

This Member Qualifies For Medicare, Medicaid, TriCare Or Tribal Coverage

This Member Uses Nicotine Products

D5 Additional Comments

Add Dependent 6 *

Yes

Dependent 6 Information

D6 Full Name

D6 Date of Birth

D6 Gender

D6 Providers, Diagnosis and RX

D6 Annual Income and Source

D6-If Yes, Select Box

This Member Will Be Claimed On My Taxes For The Coverage Year

This Member Needs To Added To My Coverage

This Member Has Coverage Available Elsewhere But Declined The Coverage (didn't like or too expensive)

This Member Has Coverage Available Elsewhere But Is Waiting For Enrollment Period

This Member Qualifies For Medicare, Medicaid, TriCare Or Tribal Coverage

This Member Uses Nicotine Products

D6 Additional Comments

Add Dependent 7 *

Yes

Dependent 7 Information

D7 Full Name

D7 Date of Birth

D7 Gender

D7 Providers, Diagnosis and RX

D7 Annual Income and Source

D7-If Yes, Select Box

This Member Will Be Claimed On My Taxes For The Coverage Year

This Member Needs To Be Added To My Coverage

This Member Has Coverage Available Elsewhere But Declined The Coverage (didn't like or too expensive)

This Member Has Coverage Available Elsewhere But Is Waiting For Enrollment Period

This Member Qualifies For Medicare, Medicaid, TriCare Or Tribal Coverage

This Member Uses Nicotine Products

D7 Additional Comments

Add Dependent 8 *

Yes

Dependent 8 Information

D8 Full Name

D8 Date of Birth

D8 Gender

D8 Providers, Diagnosis and RX

D8 Annual Income and Source

D8-If Yes, Select Box

This Member Will Be Claimed On My Taxes For The Coverage Year

This Member Needs To Be Added To My Coverage

This Member Has Coverage Available Elsewhere But Declined The Coverage (didn't like or too expensive)

This Member Has Coverage Available Elsewhere But Is Waiting For Enrollment Period.

This Member Qualifies For Medicare, Medicaid, TriCare Or Tribal Coverage

This Member Uses Nicotine Products

D8 Additional Comments

Add Additional Dependents Here

LET'S BUILD YOUR CUSTOM PLAN

Health insurance benefits are highly customizable. This means that we can select higher or lower levels of coverage based on your specific health needs and your financial situation.

In this last section, we will ask series of multiple choice and yes or no health questions that will help us narrow down from the thousands of options that are available to only those options that match your specific needs.

I will be asking for your financial snapshot as well. There are numerous programs available to almost every income level and we help determine which programs (if any) that you qualify for. Your answers don't have to be exact so if you're unsure, just give us your best guess.

IMPORTANT MESSAGE!

Once you click the submit button, you'll be taken directly to my calendar where you can book your 30 minute plan recommendation appointment (this might already be booked). This meeting will take approximately 30 minutes over the phone and computer (best for viewing). We will spend this time going over your proposal and recommendations as well as all of your questions.

It will take approximately 24-48 business hours to complete your assessment. In the meantime, if you think of anything that might be important for us to know, or if you have any questions, please reach out via text, email or phone.

Are there any additional comments you'd like to add?

OFFICE: 866-758-7229 - CALL OR TEXT: 520-272-5950]
EMAIL: tracy@snibrokers.com - ON THE WEB: www.snibrokers.com

Contact Us

Mon-Fri : 9:00 - 6:00 PM

Sat: 9:00 AM - 1:00 PM

tracy@snibrokers.com

866-758-7229

520-272-5950

7150 E Camelback Rd Ste 310, Scottsdale AZ 85251

Get Started Now

THE LEGAL STUFF

To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1- 877-486-2048), 24 hours a day/7 days a week). If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.

* Medicare Advantage, Medicare Supplemental Insurance, and Part D options can be explored.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov. , 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options. Attention: This website is operated by Cornett Consulting Insurance Agency, Inc. and is not the Health Insurance Marketplace® website.

Cornett Consulting Insurance Agency. is licensed in AZ, FL, TX & VA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

Cornett Consulting Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call your plan’s customer service phone number for more information about your specific benefits, limitations, exclusions and costs.

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