By digitally signing this document, I authorize the following licensed agents and agency to act as my health insurance representatives for myself and my entire household, if applicable, for the purpose of enrolling in a Qualified Health Plan offered through the Federally Facilitated Marketplace for coverage under the 2026 plan year:

• Get Covered USA (NPN: 17675512)

• Jeffrey Mercado (NPN: 11206123)

• Jurany Andrea Mercado (NPN: 17743547)

• Ana Arango (NPN: 20519043)

• James Perkins (NPN: 20756724)

• Nicholas Riccardi (NPN: 20120220)

• Marcel Rodrigues (NPN: 17335400)

Authorization of Use of Information

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:

• 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, CHIP, or advance tax credits to help pay for Marketplace premiums.

• Providing ongoing account maintenance and enrollment assistance, as necessary.

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

Data Privacy and Security

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 secure when collecting, storing, and using my information for the stated purposes.

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 am not required to share additional personal information about myself or my health with my Agent beyond what is necessary for eligibility and enrollment purposes.

For details on how your data is collected, stored, and used, please review our Privacy Policy and Terms of Service.

Consent to Communication

By submitting this form, I also agree to receive marketing calls and text messages from Universal Life and Health Insurance Agency Co. DBA Get Covered USA at the phone number I provided, including via automated technology.

• Consent is not a condition of enrollment.

• Message and data rates may apply.

• I may revoke my consent at any time by replying STOP to text messages or by contacting the agency directly.

Revocation of Consent

I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by phone, email, or U.S. Postal Service (USPS).