1. APPOINTMENT OF AGENCY AND AUTHORIZED AGENTS

I, [Name of Primary Applicant], 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:

• Alec Kruki (Principal Agent In Charge)Email: alec@yourvitalguard.comNPN: 19734040
• Alex GundlachEmail: alexg@yourvitalguard.comNPN: 21344037
• Aaron Du BoisEmail: aaron@yourvitalguard.comNPN: 20550415
• Amy KrukiEmail: amy@yourvitalguard.comNPN: 21755303
• Andrew NorthEmail: andrew@yourvitalguard.comNPN: 20506758
• Cynthia HollisEmail: shanelle@yourvitalguard.comNPN: 20279495
• Kaila ConnollyEmail: kaila@yourvitalguard.comNPN: 21689230
• Jackson MosesEmail: jackson@yourvitalguard.comNPN: 21774972
• Anderson PierreEmail: anderson@yourvitalguard.comNPN: 21306530

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.

3.1. 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.

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. NON-CIRCUMVENTION AND NON-INTERFERENCE

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
• To the best of your knowledge and belief, all of the information that you provided today is accurate and that you authorize us, Vital Guard Insurance Services to be your agency and access, submit or otherwise necessarily edit/change/update your application with/to The Marketplace.
• I authorize us, Vital Guard Insurance Services, to manage your policy by enrolling today. This includes re-enrolling me into my plan or a similar plan if changes occur due to third-party action and authorizing us to renew this plan for the upcoming year if needed. By signing this agreement, I agree to this provision.
• We have your permission to handle any inquiries from The Federal Marketplace about your application, including (but not necessarily limited to) helping with any paperwork needed to keep your application/policy active and/or valid and to submit any/all documentation requested by The Federal Marketplace on your behalf if The Marketplace asks about your application.
• I qualified for a Special Enrollment Period (SEP) due to your recent State SEP, loss of coverage, CSR level, Medicaid denial or other/etc.
• I grant Vital Guard Insurance Services express consent to text, email or call you about my coverage, including (but not necessarily limited to) updates to/about your policy and/or information on future enrollment periods and that I consent to Vital Guard Insurance Services contacting me in one of these forms about any/all updates, changes or other necessary information for me to receive about my Marketplace application or my plan with my specific carrier.
• I understand that if we determine Vital Guard Insurance Services determines that I/we have active Medicare Coverage, my application with Medicare can and will be canceled upon submission of my Marketplace application.
• I acknowledge that these authorizations remain effective for 365 calendar days, or until I choose to revoke them, whichever occurs first, and that to revoke any consent I may contact customer service at (866)-949-3404, call or email my enrolling agent at their email address or direct phone number or to email Vital Guard Insurance Services at Info@yourvitalguard.com.

AGENCY INFORMATION

Agency Name:

Vital Guard LLC DBA Vital Guard Insurance Services

Agency NPN:

21306412

Phone:

(866) 949-3404

Email:

Info@yourvitalguard.com

APPLICANT ATTESTATION

Your choice, always; By signing this consent agreement, you acknowledge and understand that you have the right to select, change, or revoke your agent or agency of their consent to act on your behalf at any time and that your consent to work with Vital Guard LLC DBA Vital Guard Insurance Services is entirely voluntary.

DIGITAL SIGNATURE COMPLIANCE NOTICE

Electronic signatures captured through this form are valid under the Electronic Signatures in Global and National Commerce Act (E-SIGN Act, 15 U.S.C. § 7001 et seq.) and shall have the same legal force as a handwritten signature. I certify that the information I have provided is true and correct to the best of my knowledge. I have read, understand, and voluntarily agree to the terms and conditions of this consent as outlined above.