AUTHORIZATION, CLIENT ATTESTATION & CONSENT Health Insurance Marketplace & HealthSherpa I hereby appoint 9ja Insurance as my authorized representative for all matters related to my health insurance enrollment and coverage. By executing this agreement, I certify and acknowledge: 1. Explicit Consent I authorize 9ja Insurance to complete, submit, update, and maintain my Marketplace application, select plans, and manage renewals on my behalf. 2. HealthSherpa Authorization I consent to 9ja Insuranceās access to HealthSherpa and CMS systems using my personal information strictly for enrollment, renewal, and servicing purposes. 3. Renewal Authority I authorize automatic renewal or reassignment to a comparable plan if necessary to prevent coverage gaps. 4. Client-Initiated Engagement I initiated this relationship with 9ja Insurance without solicitation. I independently sought the services of 9ja Insurance. I knowingly declined continued representation from any prior agent or agency. 5. Waiver of Prior Agent Affiliation I affirm that I no longer desire representation by any previous agent or agency and hereby elect 9ja Insurance as my sole agent of record. 6. Non-Compete & Solicitation Disclaimer I understand that 9ja Insurance did not induce or solicit me in violation of any agreement. Any prior contractual limitations are my responsibility, and I agree that 9ja Insurance bears no liability related to such agreements. 7. Change Reporting & Accuracy I agree to report all material changes and confirm that the information provided is complete and accurate. This authorization remains effective until revoked in writing. Written Revocation Address: 9ja Insurance 5900 Balcones Drive Suite 100 Austin, TX 78731 Client Name:Client Signature:Date of birth MM slash DD slash YYYY Date MM slash DD slash YYYY
