Vital Guard LLC DBA Vital Guard Insurance Services — Client Consent and Agent of Record Authorization

Please read this agreement, fill in its boxes and initial each disclosure, then press Sign at the foot of it. Signing is voluntary. Nothing on this page asks for your Marketplace password or logs in as you.

Your agent

This box is not part of the agreement below. The agent named here fills in the agreement's agent lines (Disclosures 5 and 12 and the enrolling agent's phone and email) and is included in what this page sends to the agency.

Your agent for this consent

This is the agent who will contact you.

Scott Gordon

NPN 21061074

(754) 732-1996

scott@yourvitalguard.com

This form will be used solely by your enrolling agency for the purposes of enrolling you and any additional applicants into an insurance plan(s) or products of your choice.

Client Consent and Agent of Record Authorization

Please read this agreement, complete the applicable fields, initial each enrollment disclosure, and sign below. Signing is voluntary. This agreement does not ask for your Marketplace password.

Primary applicant first name: (required)Primary applicant last name: (required)

1 Appointment Of Agency And Authorized Agents

I, the individual identified in the signature block below, hereby authorize Vital Guard LLC DBA Vital Guard Insurance Services (“Agency”), along with the following licensed agents (collectively referred to as “Authorized Agents”), to act as my health insurance Agent(s)-of-Record (“AOR”) for myself and, if applicable, my household:

Authorized agent	Email	NPN
Alec Kruki (Principal Agent In Charge)	alec@yourvitalguard.com	19734040
Alex Gundlach	alexg@yourvitalguard.com	21344037
Aaron Du Bois	aaron@yourvitalguard.com	20550415
Amy Kruki	amy@yourvitalguard.com	21755303
Andrew North	andrew@yourvitalguard.com	20506758
Cynthia Hollis	shanelle@yourvitalguard.com	20279495
Kaila Connolly	kaila@yourvitalguard.com	21689230
Jackson Moses	jackson@yourvitalguard.com	21774972
Anderson Pierre	anderson@yourvitalguard.com	21306530
Scott Gordon	scott@yourvitalguard.com	21061074
Blaze Lindquist	ember@yourvitalguard.com	22174391
Alexandre Jr. Alvarenga-Freire	alexjr@yourvitalguard.com	21632828

This authorization shall remain in effect for 365 calendar days from the date of execution of this agreement unless revoked in accordance with the provisions herein.

2 Scope Of Authorization

I grant permission for the Agency and its Authorized Agents to:

Access, review, and manage my Marketplace application(s).
Submit, update, and maintain eligibility and enrollment for Qualified Health Plans (QHPs), Medicaid, CHIP, and Advanced Premium Tax Credits (APTC).
Communicate with CMS, the Federally Facilitated Marketplace (FFM), HealthSherpa, insurance carriers, and all Enhanced Direct Enrollment (EDE) platforms.
Maintain and service my policy, including updates, renewals, eligibility changes, and compliance actions.
Use and disclose my personally identifiable information (PII) and protected health information (PHI) strictly as necessary to perform these services, in full compliance with applicable federal and state laws.

3 Multiple Agent of Record Authorization

I acknowledge and agree that:

Any Authorized Agent listed in this agreement may act individually or collectively as my Agent-of-Record.
The Agency retains full discretion to assign, reassign, or transition servicing responsibilities between Authorized Agents at any time without additional notice or consent.
All actions taken by any Authorized Agent shall be deemed actions of the Agency.
This authorization applies across CMS.gov, the Federally Facilitated Marketplace (FFM), HealthSherpa, and all Enhanced Direct Enrollment (EDE) platforms.

Principal Agent in Charge Designation And Authority

I acknowledge and agree that Alec Kruki (NPN: 19734040, Email: alec@yourvitalguard.com) is designated as the Principal Agent In Charge for Vital Guard LLC DBA Vital Guard Insurance Services.

I understand that, in some cases and where operationally appropriate, the Principal Agent In Charge may be designated as the primary Agent-of-Record (AOR) under standard operating conditions, unless otherwise required for compliance, carrier-specific requirements, or operational necessity on my application(s), policy(policies), or Marketplace account(s).

I further acknowledge and agree that any Authorized Agent of the Agency may, within the scope of applicable federal and state law, act in good faith on behalf of the Principal Agent In Charge as an assisting or servicing agent in connection with my application, enrollment, policy servicing, or related communications.

The applicant acknowledges that the designation of a Principal Agent In Charge does not limit the authority of the Agency or its Authorized Agents but instead establishes a centralized point of accountability for all actions taken under this agreement.

All such actions taken by Authorized Agents on behalf of the Principal Agent In Charge shall be deemed valid, authorized, and binding under this agreement, provided such actions are performed in compliance with applicable laws and regulations governing licensed insurance activity.

I understand that this provision is intended to ensure continuity of service, operational efficiency, and proper representation while maintaining centralized accountability under the Principal Agent In Charge.

4 Agency Control Substitution And Continuity

I acknowledge and agree that:

The Agency may substitute, replace, or reassign any Authorized Agent at its sole discretion.
The Agency may designate additional licensed agents as Authorized Agents when necessary for servicing, compliance, or operational continuity.
Any such substitution or addition shall not invalidate or otherwise affect this agreement.
The Agency retains full authority over representation, servicing, and administrative control throughout the term of this agreement.

Future Authorized Agents

I acknowledge and agree that the Agency may, from time to time, contract with, appoint, or onboard additional licensed agents, representatives, or affiliates after the date of execution of this agreement.
Any such individuals shall automatically be considered “Authorized Agents” under this agreement upon becoming affiliated with the Agency, provided they are properly licensed and appointed in accordance with applicable federal and state regulations.
I expressly consent to such future Authorized Agents acting as my Agent-of-Record under the same terms and conditions outlined herein, without requiring additional notice, disclosure, or re-execution of this agreement.
All actions taken by any future Authorized Agent shall be deemed actions of the Agency and shall carry the same authority, protections, and limitations as those explicitly named in this agreement.

5 Duration And Revocation

This agreement shall remain in effect for 365 calendar days unless revoked earlier by:

Email
Text message
Verbal request on a recorded line
All revocation requests are subject to verification as outlined below

6 Revocation Verification Provision

To protect against unauthorized or fraudulent changes:

The Agency may contact me via phone, email, or text message for up to 365 calendar days following any revocation request.
Such communication shall be strictly limited to identity and intent verification.
No marketing or solicitation will occur during this verification period.
I may stop these verification contacts at any time, by any of the methods listed in Section 5. The Agency will honor that request immediately, and no further verification contact will be made.
Upon confirmation of valid revocation, the Agency will cease all representation unless new consent is provided.

7 Agent of Record Exclusivity And Fraud Prevention

I acknowledge and agree that:

This agreement represents my active and controlling Agent-of-Record authorization.
Any attempt by a third party to alter, override, or access my Marketplace application without verified consent may be considered unauthorized activity.
The Agency and its Authorized Agents may verify any AOR changes within a 30-day review window.
If unauthorized changes are detected, the Agency and its Authorized Agents are authorized to resume AOR status on my behalf.

8 Commission Protection And Financial Interest

I acknowledge and agree that:

The Agency and its Authorized Agents have invested time, expertise, and resources into my enrollment and ongoing servicing.
The Agency retains a legitimate financial interest in commissions, overrides, and compensation associated with my policy.
Any unauthorized attempt to replace the Agency or interfere with its compensation may constitute tortious interference with a business and/or contractual relationship under applicable law.
Unauthorized AOR changes may negatively impact policy servicing, compliance, and coverage continuity.

9 Noncircumvention And Noninterference

I agree that:

I will not knowingly authorize any third party to bypass, replace, or circumvent the Agency during the active term of this agreement without direct confirmation.
Any agent or entity attempting to induce or facilitate such action without proper authorization may be subject to compliance reporting.
This provision is intended to protect against fraud, misrepresentation, and unauthorized manipulation of Marketplace records.

10 Cooperation Audit And Injunction Provision

I expressly authorize the Agency to:

Initiate fraud, compliance, and audit investigations with CMS, the Federally Facilitated Marketplace, HealthSherpa, or any EDE platform.
Request access logs, audit trails, and enrollment records related to my application or policy.
Take corrective action, including reinstatement of Agent-of-Record status where appropriate.
Pursue administrative or injunctive remedies where permitted to prevent unauthorized access or interference.

11 Client Rights And Consumer Protection

I acknowledge:

I may revoke this agreement at any time.
I retain full freedom to seek alternative representation or coverage.
This agreement is designed to protect my Marketplace account from unauthorized access or fraud.
My personal data will be handled securely and only used as necessary to provide services.

12 Severability

If any provision, section, or clause of this agreement is determined by any court, regulatory authority or governing body to be invalid, illegal, unenforceable, or otherwise void, such determination shall apply only to the specific provision, section, or clause in question. All remaining provisions of this agreement shall continue in full force and effect as though the invalid, illegal, unenforceable or void portion had never been included. Each provision of this agreement is agreed to and intended to be construed independently, and the invalidity or unenforceability of any single provision shall not affect or otherwise impair the validity, enforceability or interpretation of any other provision contained herein. The parties expressly agree that it is their intent that this agreement, and each individual obligation and authorization within it, remain fully valid, binding and enforceable to the maximum extent permitted by applicable law.

13 Governing Acknowledgment

By signing below, I confirm that:

I have read and understand this agreement in its entirety.
I voluntarily authorize the Agency and its Authorized Agents.
I understand my rights regarding consent, revocation, and representation.

Enrollment Disclosures

Initial each disclosure after reviewing it. Enter N/A only where the disclosure states it may not apply. Complete the application review and plan selection before the application is submitted.

1 Enrollment Summary

The individuals to be enrolled, the carrier, the plan, the monthly premium, and the effective date have been reviewed with me. The following information identifies the enrollment I am authorizing.

Enrollment discussion date (required)Consumer initials (required)

2 Plan Benefits and Cost Sharing

My agent has reviewed the plan benefits and the following costs with me. I understand that a $0 monthly premium, if applicable, does not mean that all covered care is free.

Consumer initials (required)

3 Special Enrollment Period

If I am applying through a Special Enrollment Period (SEP), my agent has explained the specific qualifying event and SEP being requested. I confirm that the qualifying event information below is accurate and authorize the Agency to submit the request for an SEP eligibility determination. The Marketplace determines eligibility.

Consumer initials (required — initials, or N/A if this does not apply)

4 Marketplace Access and Application Submission

I authorize Vital Guard LLC DBA Vital Guard Insurance Services and its Authorized Agents to search the Marketplace for existing applications, access and use the information needed to assist me, and prepare and submit my Marketplace application within the scope and duration of this agreement. This authorization must be provided before the Agency begins the assistance it covers.

Date agency consent was providedConsumer initials (required)

5 Application Accuracy and Attestations

I have reviewed my completed Marketplace eligibility application before submission and confirm that the information is accurate and complete to the best of my knowledge and belief. My assisting agent explained the attestations at the end of the application, gave me an opportunity to ask questions, and I understand those attestations. I knowingly confirm and authorize the household income projection entered on the application.

Application review date (required)Assisting agent full nameAssisting agent NPNConsumer initials (required)

6 Consent for Enrolled Household Members

I expressly authorize enrollment for the individuals identified in the enrollment summary. I confirm that their enrollment information has been reviewed and that I am entitled to provide consent for them as the application filer or their authorized representative. No additional person may be enrolled under this agreement without valid consent.

Consumer initials (required)

7 Policy Management Renewals and Reenrollment

I authorize Vital Guard LLC DBA Vital Guard Insurance Services to manage my policy, including the enrollment identified above and assistance with renewal or reenrollment into my plan or a similar plan when needed. Before reverting changes made by a third party, the Agency must check with me whether I authorized those changes. Before submitting any new or updated eligibility application, including a renewal or a reversal of changes, the Agency must document my review and confirmation of the accuracy of that application. This requirement applies to all application changes and reinstatement activity described in this agreement.

Consumer initials (required)

8 Marketplace Inquiries and Documentation

I authorize Vital Guard LLC DBA Vital Guard Insurance Services to handle inquiries from the federal Marketplace about my application, help with required paperwork, and submit documentation requested by the Marketplace on my behalf.

Consumer initials (required)

9 Coverage Communications

I consent to Vital Guard LLC DBA Vital Guard Insurance Services contacting me by text message, email, or telephone about my coverage, policy updates, future enrollment periods, and other necessary information about my Marketplace application or carrier plan.

Consumer initials (required)

10 Medicare Coverage

I understand that submitting a Marketplace application does not cancel Medicare coverage. I will tell my agent if I have Medicare before any Marketplace application is submitted. Medicare is separate from Marketplace coverage; this agreement does not authorize cancellation of Medicare.

Consumer initials (required)

11 Duration and Revocation

These authorizations remain effective for 365 calendar days from execution of this agreement, or until I revoke them, whichever occurs first. I may revoke consent by calling customer service at (866) 949-3404, contacting my enrolling agent by telephone, text message, or email, or emailing Info@yourvitalguard.com. I retain the right to select, change, or revoke my agent or agency at any time.

Consumer initials (required)

12 Marketplace Three Way Call Authorization

If a three way Marketplace call is needed, a Marketplace representative will confirm the details needed to complete my application. I may authorize my named agent to access and assist with my Marketplace account for up to 365 days and, when permitted, finish the call after I leave the line. I understand that I must provide this separate authorization directly to the Marketplace Call Center; signing this form alone does not create Call Center access or guarantee that coverage has started. Enter N/A if no three way call or Call Center authorization is used.

Agent to be authorized at the Call CenterAgent NPNAuthorization duration is 365 days (required)

13 Prior Authorizations and Conflicting Applications

If the Marketplace representative identifies prior agent authorizations or conflicting applications, my agent will explain the specific action proposed before asking for revocation, cancellation, or termination. I authorize only the actions specifically identified below. I understand that the Agency may not cancel coverage or revoke another agent authorization merely because another application or agent exists. Enter N/A if no such action is requested.

Consent to revoke any and all prior agent authorizations: (required)YesNoN/A

Additional Plan Type Disclosures

14 Limited Medical Plan

I understand that a limited medical plan provides coverage only for specified medical services or pays restricted benefits. It may limit the number of covered visits, the amounts payable, or the conditions and treatments covered. Depending on the policy, hospital stays, emergency care, surgery, prescriptions, or preexisting conditions may be excluded or limited. This is not the same as comprehensive ACA compliant major medical coverage. I may owe substantial medical costs beyond the plan's benefits and must review its policy and benefit schedule.

Consumer initials (required)

15 Fixed Indemnity Plan

I understand that a fixed indemnity plan pays a predetermined cash amount when a covered event or service occurs, such as a stated amount for each covered day in a hospital. The payment is based on the policy's benefit schedule rather than my actual medical bill and may be much less than the cost of care. Fixed indemnity excepted benefits are supplemental coverage, are not comprehensive major medical insurance, and do not count as MEC. I remain responsible for costs the benefit does not pay.

Consumer initials (required)

16 Minimum Essential Coverage Plan

I understand that minimum essential coverage (MEC) is a legal category of health coverage recognized under the Affordable Care Act. Marketplace health plans, most employer health plans, and certain government programs qualify as MEC. MEC status alone does not mean a plan provides comprehensive medical benefits or meets the separate minimum value standard. Plans marketed specifically as MEC plans may provide limited benefits. I must review the actual plan documents to determine which services, exclusions, and benefit limits apply.

Consumer initials (required)

17 MEC Premium Tax Credit Disclaimer

I understand that if I enroll in an employer-sponsored plan that is MEC, I will no longer qualify for a Marketplace premium tax credit for my own coverage for the affected months, even if I qualified before enrolling and even if the employer plan is unaffordable or does not provide minimum value. Other disqualifying MEC, such as qualifying government coverage, can also end tax-credit eligibility. Marketplace plans themselves are MEC; individual-market coverage does not automatically disqualify me, but a premium tax credit cannot pay for coverage purchased outside the Marketplace. I must report other coverage to the Marketplace and may have to repay advance tax credits paid for months when I am ineligible.

Consumer initials (required)

Agency Information

Vital Guard LLC DBA Vital Guard Insurance Services

Agency NPN 21306412

Customer service (866) 949-3404

Email Info@yourvitalguard.com

Applicant Attestation

By signing this agreement, I acknowledge that I have the right to select, change, or revoke my agent or agency and its consent to act on my behalf at any time. My consent to work with Vital Guard LLC DBA Vital Guard Insurance Services is entirely voluntary.

Signature and Contact Details

Consumer or authorized representative name (required)If representative relationship or authority (required if the name above is not the primary applicant's; otherwise optional)Consumer or representative signature (required — type your full legal name)

You may also draw your signature below. Drawing is optional; the typed name above is the signature either way.

Date signed (required)Enrolling agent direct phone numberEnrolling agent emailConsumer phone number (required)Consumer email address (optional)

Electronic Signature Notice

If I sign electronically, I intend my electronic signature to have the same legal effect as a handwritten signature under applicable law, including the E-SIGN Act, 15 U.S.C. § 7001 et seq. I certify that the information I provided is true and correct to the best of my knowledge. I have read, understand, and voluntarily agree to this consent.

Sign

Record my approximate location — city and region, from my internet connection.

This is approximate and comes from the internet connection, not from your phone's GPS, so it can be wrong if you use a VPN or private relay. It is added by Vital Guard when this form is sent, so it is not part of the copy you keep. Leaving the box unticked means no location is recorded at all.

I agree that my electronic signature has the same legal effect as a handwritten signature, and that my copy of this agreement records the date, time and time zone reported by my browser.

By typing my full legal name in the signature box above and pressing Sign, I adopt that name as my signature and apply my electronic signature to this agreement as it is filled in above.

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