I, Victor M Rosa, give my permission to MARIA CARIDAD ALVAREZ PUJOL to act as a health-insurance agent or broker for me—and for my entire family, if applicable—for the purpose of enrolling me in a Qualified Health Plan offered through the federally facilitated Marketplace. By giving my consent to this agreement, I authorize the above-named agent to view and use the confidential information I provide in writing, electronically, or by phone solely for one or more of the following purposes:

1. Locating an existing Marketplace application;
2. Completing an eligibility and enrollment application for a Marketplace Qualified Health Plan or other government insurance-affordability programs such as Medicaid, CHIP, or advance tax credits to help pay Marketplace premiums;
3. Providing ongoing account maintenance and enrollment assistance as needed; or
4. Responding to Marketplace inquiries regarding my Marketplace application.

I understand that the agent will not use or share my personally identifiable information (PII) for purposes other than those listed above. The agent will ensure that my PII is kept private and secure when collecting, storing, and using it for the purposes mentioned above.

I confirm that the information I provide for my Marketplace eligibility and enrollment application will be true to the best of my knowledge and belief. I understand that I am not required to share additional personal or health information 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 notifying the agent in writing or by contacting them directly. The agent will provide further instructions on the steps necessary to terminate consent.

Primary writing agent name: MARIA CARIDAD ALVAREZ PUJOL

Agent National Producer Number (NPN): 20717453

Phone number: 786-486-1455

Email address: smartinsurance23@gmail.com

Primary household contact and/or authorized representative name: Victor M Rosa

Phone number: +15615680619

Email address: vrosajr@gmail.com

Date: 2025-08-25