Confirm your agent of record

If someone changed the agent listed on your Marketplace application without your permission, you can say so in writing here. Your agent asked you to visit this page. The form is voluntary, it costs nothing, and you can stop at any point.

You were referred by the number ending in This number tells us which agency asked you to come here. It does not identify you, and it does not tell us which application is yours — the form asks for that.

Consumer Attestation — Possible Unauthorized Change to My Marketplace Application

Transaction-specific · Voluntary and revocable · Template for attorney finalization — not legal advice

Our records indicate the agent of record on your Health Insurance Marketplace application may have changed, or a submission may have been made, in a way you may not have requested. This form lets you state, in your own words, what you personally know. If you choose, you may also authorize Vital Guard Insurance Services to ask the Marketplace/CMS (and, if applicable, a state regulator) to review it. Signing is completely voluntary. This is not authorization to enroll you, change your plan, access your Marketplace account using your credentials, or act as you.

Section 1 — About you

Full name * Best phone

State where you live * ZIP code

Your state tells us which state insurance department this would go to, if you ask for that below. Without it, a state submission cannot be routed and a person has to handle it by hand.

I consent to Vital Guard Insurance Services contacting me about this specific matter using my preferred method.

Location stamp (optional)

Your browser will ask your permission. You may say no — the form works either way, and it will record honestly whether you allowed it. This is never asked for on its own; only when you press the button below.

Device location: not requested.

Please do NOT enter your Social Security number or full date of birth on this form.

Section 2 — The application this is about

Marketplace Application ID (if known) Coverage year

Insurance carrier / plan (if known)

Section 3 — My statement, in my own words

Check all that apply based only on what you personally know:

I did NOT authorize any agent other than my chosen agent to be listed as my agent of record. I did NOT authorize a change to my Marketplace application. I did NOT authorize a new application to be submitted on my behalf. I did NOT give consent to be contacted by the other agent or agency about this application. I became aware of this on or around, and here is what happened (your own words):

Section 4 — What I authorize (limited to the application above)

Submit a request, complaint, or supporting information to the Health Insurance Marketplace / CMS asking them to review whether my authorization existed, and attach this attestation. Submit the same or related information to my state Department of Insurance, if applicable. Communicate with me about status, documentation, and resolution of this matter.

This does NOT permit anyone to log into or access my Marketplace account using my credentials, make plan changes for me, or act as me.

Section 5 — What you should know

Vital Guard Insurance Services may have been (or may claim to have been) your agent of record and may have its own business interest in this matter. You are signing with that understanding.
Signing is voluntary. You may contact the Marketplace, CMS, your carrier, or your state Department of Insurance directly without signing this form.
This form does not authorize Vital Guard Insurance Services to contact another agent with an accusation.

Section 6 — Revocation

I may revoke this authorization at any time in writing. Revocation is effective when received and does not undo submissions already made.

Section 7 — System-detected information

Populated from available Marketplace/ledger/carrier/agency records for identification and routing. Included for context; it does not require you to make any legal conclusion about the other party.

Detected agent/agency now on record (if known)—

Detected NPN / license identifier (if known)—

Detection source / date or report period—

Internal case ID (if applicable)—

Section 8 — Acknowledgment & signature

The statements I have made above are true and accurate to the best of my personal knowledge. I understand that knowingly providing false information in connection with a federal health-insurance matter may have legal consequences.

Type your full legal name to sign

Or sign below:

I agree my electronic signature has the same effect as a handwritten signature, and the system may record audit details (date, time, IP, device).

Template — counsel must finalize before use. Not legal advice. Delivered securely to your agency's records system; VitalBot does not retain a copy.

What happens next

You fill in the form and download the completed copy.
You send that copy to your own agent, using the contact details the form gives you.
Your agent reviews it and decides what to do next with you.

Nothing is sent anywhere when you fill this page in. The completed form downloads to your own device, and you choose who receives it.