Glacier Consulting and Insurance Solutions, LLC
Request a Quote!
Call Us: 907-357-2707
Menu
  • Home
  • About
  • Personal
    • Auto Insurance
    • Homeowners Insurance
    • ATV
    • Boat & Watercraft
    • Collector Car
    • Condo Insurance
    • Earthquake
    • Flood Insurance
    • Individual Annuities
    • Individual Dental Insurance
    • Individual Disability
    • Individual Health Insurance
    • Individual Life Insurance
    • Individual Vision Insurance
    • Jewelry Floaters
    • Landlord Insurance
    • Long Term Care
    • Manufactured / Mobile Home
    • Medicare Advantage Plans
    • Medicare Supplements
    • Motor Home
    • Motorcycle Insurance
    • Personal Umbrella
    • Pet Insurance
    • Prescription Drug Plans
    • Recreational Vehicle
    • Renters Insurance
    • SR 22
    • Travel Insurance
  • Business
    • Apartment Building Owners
    • Auto Body Shops
    • Auto Dealers
    • Bonds
    • Builders Risk
    • Business Owners Policy (BOP)
    • Commercial Auto
    • Commercial Property
    • Commercial Umbrella
    • Contractors
    • Crop Insurance
    • Cyber Liability
    • Directors & Officers
    • EPLI Insurance
    • Employee Benefits
    • Equine Insurance
    • Errors and Omissions
    • Farm & Ranch
    • General Liability
    • Group Dental Insurance
    • Group Health Insurance
    • Group Life Insurance
    • Group Vision Insurance
    • Non-Profit
    • Outdoor Insurance
    • Professional Liability
    • Restaurant
    • Special Event Insurance
    • Truck & Trucking
    • Videographers
    • Workers Compensation
    • Church Insurance
    • Agribusiness
    • Retail Stores
    • Inland Marine Insurance
    • Hotel / Motel
    • Self Storage Insurance
    • Specialty Lines
  • Health
  • Quote Request
    • Apartment Building Owners
    • Auto Body Shops
    • Auto Dealers
    • Auto Insurance
    • Auto Insurance Quick Form
    • Boat & Watercraft
    • Bonds
    • Builders Risk
    • Business Owners Policy (BOP)
    • Business Quick Quote
    • Commercial Auto
    • Commercial Property
    • Condo Insurance
    • Contractors
    • Crop Insurance
    • Cyber Liability
    • Directors & Officers
    • Earthquake
    • Equine Insurance
    • Errors and Omissions
    • Farm & Ranch
    • Flood Insurance
    • General Interest
    • General Liability
    • Group Dental Insurance
    • Group Health Insurance
    • Group Life Insurance
    • Group Vision Insurance
    • Home Insurance Quick Form
    • Homeowners Insurance
    • Individual Annuities
    • Individual Dental Insurance
    • Individual Disability
    • Individual Health Insurance
    • Individual Life Insurance
    • Individual Vision Insurance
    • Jewelry Floaters
    • Landlord Insurance
    • Long Term Care
    • Manufactured / Mobile Home
    • Medicare Supplements
    • Motorcycle Insurance
    • Non-Profit
    • Outdoor Insurance
    • Personal Quick Quote
    • Personal Umbrella
    • Pet Insurance
    • Professional Liability
    • Recreational Vehicle
    • Renters Insurance
    • Restaurant
    • Truck & Trucking
    • Videographers
    • Workers Compensation
    • Church Insurance
    • Aviation / Tech
    • Hotel / Motel
  • Support
    • Payments & Claims
    • Add Driver Request Form
    • Add a Vehicle Form
    • Agent Authorization
    • Auto ID Card Request
    • Certificate of Insurance
    • Change of Address Form
    • Commercial Renewal Review
    • Online Claim Form
    • Personal Renewal Review
    • Policy Change Request
    • Questions & Comments
    • Remove Driver Form
    • Remove Vehicle Form
    • Submit A Testimonial
    • Survey
    • Text Messaging Opt-in
  • Resources
    • Our Companies
    • Frequently Asked Questions
    • Helpful Links
    • Common Insurance Terms
    • Privacy Policy Statement
    • Site Map
    • Refer a Friend
    • Insurance Dictionary
    • Write a Review
  • Contact
  • Facebook
  • LinkedIn
  • Home Page
  • Secure Form

Secure Agent Authorization Form

 
Your Name:
First Last

Agent Authorization

I, , give my permission to (missing data) to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. 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:

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

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 safe when collecting, storing, and using my PII for the stated purposes above.

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 do not have to share additional personal information about myself or my health 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.

Name of Primary Writing Agent: (missing data)
Agent National Producer Number:
Phone Number: 907-357-2707
Email Address: jamie@myglacierinsurance.com

Name of Primary Household Contact and/or Authorized Representative:

Website Disclaimer - Review Carefully:

This is a solicitation for insurance. Insurance coverage cannot be bound or changed via submission of this online form/application, e-mail, voicemail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent. Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.
FacebookLinkedIn
  • Navigation
  • Home
  • About
  • Quote Request
  • Support
  • Resources
  • Payments & Claims
  • Our Companies
  • Contact
  • Privacy Policy Statement
  • Personal Lines
  • Auto Insurance
  • Homeowners Insurance
  • Individual Health Insurance
  • Medicare Supplements
  • Individual Life Insurance
  • SR 22
  • Individual Disability
  • Earthquake
  • Flood Insurance
  • Landlord Insurance
  • Commercial Lines
  • Employee Benefits
  • Workers Compensation
  • Business Owners Policy (BOP)
  • Group Health Insurance
  • Commercial Auto
  • Commercial Property
  • Cyber Liability
  • Builders Risk
  • Commercial Umbrella
  • Bonds
  • Quote Request Forms
  • Apartment Building Owners
  • Auto Body Shops
  • Auto Dealers
  • Auto Insurance
  • Auto Insurance Quick Form
  • Boat & Watercraft
  • Bonds
  • Builders Risk
  • Business Owners Policy (BOP)
  • Business Quick Quote
201 E. Swanson Ave. Suite #7 Wasilla, AK 99654 | Phone: 907-357-2707 | Contact Us | Get Map
Mailing Address:  189 E. Nelson Ave PMB 213  Wasilla, AK 99654
Located in Wasilla, Alaska. We also serve the Anchorage, Eagle River, Houston, Palmer, and Willow areas. - Licensed in Alaska,  Arizona,  Idaho,  Montana,  Oregon and  Washington
Site by: AlicorSolutions.com • © 2025 Glacier Consulting and Insurance Solutions, LLC