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Power of Attorney and Attestment: I, the party seeking an insurance policy and/or information on a policy [the primary household contact], hereby grant permission to Wilberson Augusme [NPN: 17718515] of Reliable Insurance Groups and/or one of his agents, the authority to act on my behalf concerning health insurance matters. This includes serving as the health and/or life insurance agent or broker for myself and my entire household if applicable, enrolling in a Qualified Health Plan offered on the Federally Facilitated Marketplace, making decisions related to my health insurance, and handling renewals of my health insurance plan. By consenting to this agreement, I authorize the above-mentioned entity and its respective agents to view and use the confidential information provided by me in writing, electronically, or by telephone for purposes related to and in pursuit of items provided under the Scope of Appointment provided below.

Scope of Appointment: I appoint Wilberson Augusme NPN: 17718515 of Reliable Insurance Groups or one of his agents as my authorized representative to view and use the confidential information provided by me in writing, electronically, or by telephone for the purposes of one or more of the following: Searching for an existing Marketplace application; 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; Handling renewals and making necessary changes to my health insurance plan; Providing ongoing account maintenance and enrollment assistance, as necessary; or Responding to inquiries from the Marketplace regarding my Marketplace application.

Income Attestation: I confirm that the information I've provided regarding my income is true and accurate. I further attest that I will be making the minimum required income to qualify for subsidized healthcare under the Federally Facilitated Marketplace. I understand that this information will be used to determine my eligibility for health insurance programs and potential subsidies.

Agent of Record: By this agreement, I designate Wilberson Augusme NPN: 17718515 of Reliable Insurance Groups and/or one of his agents as my Agent of Record concerning all matters related to my health insurance. This designation allows Wilberson Augusme NPN: 17718515 of Reliable Insurance Groups and/or one of his agents to represent and assist me in all interactions with the health insurance provider.

Personally Identifiable Information (PII) Protection: I understand that Wilberson Augusme NPN: 17718515 of Reliable Insurance Groups and/or one of his agents will collect, store, and use my PII solely for the purposes mentioned above. Wilberson Augusme NPN: 17718515 of Reliable Insurance Groups and/or one of his agents commits to ensuring my PII is kept private and safe when collecting, storing, and using my PII and furthermore, will not share it for any purposes other than those explicitly for the staterposes above.

Revocation: I understand that my consent remains in effect until I revoke it. I may revoke or modify my consent at any time by contacting Wilberson Augusme NPN: 17718515 of Reliable Insurance Groups and/or one of his agents at the provided contact details below (email or phone number). 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 Reliable Insurance Groups is an insurance entity that engages in business and transactions in accordance with the Florida Statutes, including Section 668.50. I confirm and agree to conduct transactions by electronic means with Wilberson Augusme NPN: 17718515 of Reliable Insurance Groups and/or one of his agents. I further acknowledge that I may have refused to conduct these transactions by electronic means, and that this right to refuse to conduct transactions by electronic means may not be waived by agreement under Florida law. Thus, I confirm that in signing below I have agreed to conduct transactions by electronic means, knowingly and voluntarily. By signing this document, I confirm that all the information I've provided is true and accurate, and I understand the terms of this agreement. By signing below, you attest that the previously provided information constitutes the information used to create your Marketplace application and that you have reviewed this information and it is accurate. *I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties ud punder federal law if I intentionally provide false information. I have reviewed my application information above. From this day forward. Email: will@reliableinsurancegroups.com Phone number: 1800-905-5582