Common use of PII Received Clause in Contracts

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions under this Agreement, Staff Member/ Volunteer may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, including but not limited to: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status APTC percentage and amount applied Auto disenrollment information Applicant Name Applicant Address Applicant Birthdate Applicant Telephone number Applicant Email Applicant spoken and written language preference Applicant Medicaid Eligibility indicator, start and end dates Applicant Children’s Health Insurance Program eligibility indicator, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates Applicant CSR level Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status Contact Name Contact Address Contact Birthdate Contact Telephone number Contact Email Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period FFE Applicant ID FFE Member ID Gender Immigration document type and document numbers Issuer Member ID Membership in a Federally recognized tribe Net premium amount Pregnancy indicator Premium Amount, start and end dates Race/ethnicity Sex Special enrollment period reason Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) Tobacco use indicator and last date of tobacco

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions tasks contemplated under this Agreement, Staff Member/ Volunteer WBE may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, including but not limited toApplicants, Qualified Individual, or Enrollees: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status APTC percentage and amount applied Auto disenrollment information Applicant Name Applicant Address Applicant Birthdate Applicant Telephone number Applicant Email Applicant Social Security Number Applicant spoken and written language preference Applicant Medicaid Eligibility indicator, start and end dates Applicant Children’s Health Insurance Program eligibility indicator, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount Applicant Cost-sharing Reduction (CSR) CSR eligibility indicator, start and end dates Applicant CSR level Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status Contact Name Contact Address Contact Birthdate Contact Telephone number Contact Email Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period FFE Applicant ID FFE Member ID Gender Immigration document type and document numbers Issuer Member ID Membership in a Federally recognized tribe Net premium amount Pregnancy indicator Premium Amount, start and end dates Race/ethnicity Sex Credit or Debit Card Number, Name on Card Checking account and routing number Special enrollment period reason Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) Tobacco use indicator and last date of tobaccotobacco use Custodial parent Health coverage American Indian/Alaska Native status and name of tribe Marital status Race/ethnicity Requesting financial assistance Responsible person Applicant/Employee/dependent sex name Student status Subscriber indicator and relationship to subscriber Total individual responsibility amount

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions under this Agreement, Staff Member/ Volunteer CDO, may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, including but not limited to: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status APTC percentage and amount applied Auto disenrollment information Applicant Name Applicant Address Applicant Birthdate Applicant Telephone number Applicant Email Applicant spoken and written language preference Applicant Medicaid Eligibility indicator, start and end dates Applicant Children’s Health Insurance Program eligibility indicator, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates Applicant CSR level Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status status Contact Name Contact Address Contact Birthdate Contact Telephone number Contact Email Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period FFE Applicant ID FFE Member ID Gender Immigration document type and document numbers Issuer Member ID Membership in a Federally recognized tribe Net premium amount Pregnancy indicator Premium Amount, start and end dates Pregnancy indicator Race/ethnicity Sex Special enrollment period reason Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) Tobacco use indicator and last date of tobacco

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions under this Agreement, Staff Member/ Volunteer CDO, may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, including but not limited to: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status APTC percentage and amount applied Auto disenrollment information Applicant Name Applicant Address Applicant Birthdate Applicant Telephone number Applicant Email Applicant spoken and written language preference Applicant Medicaid Eligibility indicator, start and end dates Applicant Children’s Health Insurance Program eligibility indicator, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates Applicant CSR level Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status status Contact Name Contact Address Contact Birthdate Contact Telephone number Contact Email Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period FFE Applicant ID FFE Member ID Gender Immigration document type and document numbers Issuer Member ID Membership in a Federally Federally-recognized tribe Net premium amount Pregnancy indicator Premium Amount, start and end dates Pregnancy indicator Race/ethnicity Sex Special enrollment period reason Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) Tobacco use indicator and last date of tobacco

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions tasks contemplated under this Agreement, Staff Member/ Volunteer SHOP Agent/Broker may create, collect, disclose, access, maintain, store, and use the following data and PII from CMS, Consumers, Applicants, Employers, Employees, Qualified Employers, Qualified Employees, and Enrollees, including but not limited to: Access to or enrollment in employer or other health coverage Employee Personally Identifiable Information Employee Applicant Name Employee Unique Employer Code Employee Home Address Employee Applicant Mailing Address Employee Applicant Birthdate Employee Social Security Number Employee Applicant Telephone Number (and type) Employee Applicant Email Address Employee Applicant Spoken and Written Language Preference Employee Tobacco Use Indicator and Last Date of Tobacco Use Employee Sex Employee Race and Ethnicity Employer Business Name If American Indian/Alaska Native status APTC percentage Native: Name and amount applied Auto disenrollment information Applicant Location of Tribe Health Coverage Type (Individual or Family, if offered) Health Plan Name Applicant Address Applicant Birthdate Applicant Telephone number Applicant Email Applicant spoken and written language preference Applicant Medicaid Eligibility indicatorID Number Dental Plan Name and ID Number Other Sources of Coverage Accepting or Waiving Coverage Dependent information, start and end dates Applicant Children’s Health Insurance Program eligibility indicatorif applicable, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates Applicant CSR level Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status Contact including • Dependent Name Contact Address Contact Birthdate Contact Telephone number Contact Email Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period FFE Applicant ID FFE Member ID Gender Immigration document type and document numbers Issuer Member ID Membership in a Federally recognized tribe Net premium amount Pregnancy indicator Premium Amount, start and end dates Race/ethnicity Sex Special enrollment period reason Subscriber Indicator and relationship to subscriber • Dependent Date of Birth • Dependent Social Security Number • Dependent Relationship to Employee • Dependent Sex • Dependent Spoken and Written Language Preference • Dependent Race and Ethnicity • If American Indian/Alaska Native: Name and Location of Tribe • Dependent Tobacco Use Indicator and Last Date of Tobacco Use • If individual is living outside of home; name of individual, address, phone, e-mail address • Dependent Other Sources of Coverage • Dependent Accepting or Waiving Coverage • Special Circumstances for Employees and Dependents, i.e., marriage, moving, adopting children, losing eligibility for coverage under a group health plan or losing Employer contribution, or giving birth Employer Offering Coverage Information Employer Name/“Doing Business As” Employer Federal Tax filing status ID Number Employer Address Business Type Employer Attestation to SHOP Eligibility Requirements Employer Contact Information Employer Contact Name and Title Employer Contact Mailing Address (tax filerif different than employer address) Employer Contact Phone Numbers (and type) Employer Contact Spoken and Written Language Preference Employer Contact Email Address Employer Contact Fax Number Secondary Contact Name (optional) Secondary Contact Phone number (and type) Secondary Contact Fax Number Secondary Contact Email Address Secondary Contact Authorizations Employer Coverage Offered Employer-selected AV Levels (Bronze, tax dependentSilver, nonGold, or Platinum) Benchmark Plan Offer of Dependent Coverage Agent/Broker/Assister/Navigator Name, Organization Name, Contact Information, FFM User ID Employer Contribution Information: • Benchmark Plan ID number-filerMedical Plan • Benchmark Plan ID number-Dental Plan • Percentage towards Employee-Medical Coverage • Percentage towards Employee Dental Coverage • Percentage towards Dependent Medical Coverage • Percentage towards Dependent Dental Coverage • Employer Offering-Single QHP or Single Metal Level or Single Issuer • Employer Offering-Single Stand-alone Dental Plan (SADP) Tobacco use indicator and last date or multiple SADPs Category Description Offer of tobaccoStand-alone Dental Coverage Desired Effective Date of Coverage Employee Selection Due Date Waiting Period for New Hires to Enroll Employee List, including • Employee Name • Employee Date of Birth • Employee Age • Employee Social Security Number • Employee Email Address • Employee Employment Status • Employee’s Other Coverage • Number of Dependents • Dependent information, including Dependent Name • Dependent Date of Birth • Dependent Age • Dependent Social Security Number • Dependent Email Address • Dependent’s Other Coverage Payment Method options, including • Electronic Funds Transfer Information (Checking Account Number, Routing Number) • Credit Card information (Credit Card type, Name on Credit Card, Credit Card Number, Expiration Date, Signature, Signature Date) • Checking Information Employer Attestation to Consolidated Omnibus Budget Reconciliation Act (COBRA)/Medicare Compliance Questions

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions under this Agreement, Staff Member/ Volunteer may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, including but not limited to: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status APTC percentage and amount applied Auto disenrollment information Applicant Name Applicant Address Applicant Birthdate Applicant Telephone number Applicant Email Applicant spoken and written language preference Applicant Medicaid Eligibility indicator, start and end dates Applicant Children’s Health Insurance Program eligibility indicator, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates Applicant CSR level Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status Contact Name Contact Address Contact Birthdate Contact Telephone number Contact Email Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period FFE Applicant ID FFE Member ID Gender Immigration document type and document numbers Issuer Member ID Membership in a Federally recognized tribe Net premium amount Pregnancy indicator Premium Amount, start and end dates Race/ethnicity Sex Special enrollment period reason Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) Tobacco use indicator and last date of tobaccotobacco Authorization. Before Staff Member/Volunteer creates, collects, discloses, accesses, maintains, stores, or uses any of a Consumer’s PII, Staff Member/Volunteer will obtain from the Consumer the authorization required by 45 CFR 155.225(f) for Staff Member/Volunteer to create, collect, disclose, access, maintain, store, and use the Consumer’s PII to carry out the Authorized Functions listed at Section III.b of this Agreement, and will permit the authorization to be revoked at any time. This authorization is separate and distinct from any informed consent obtained pursuant to section 2(b) of Appendix A of this Agreement. The Staff Member/Volunteer should ensure that a record of the authorization provided is maintained in a manner consistent with the privacy and security standards set forth in Appendix A. Collection of PII. Except for collections, uses or disclosures that are specifically authorized by Consumers in accordance with Section 2(b) of Appendix A, PII collected from Consumers may be used only for the Authorized Functions specified in Section III.b of this Agreement.

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions tasks contemplated under this Agreement, Staff Member/ Volunteer SHOP Agent/Broker may create, collect, disclose, access, maintain, store, and use the following data and PII from CMS, Consumers, Applicants, Employers, Employees, Qualified Employers, Qualified Employees, and Enrollees, including but not limited to: Access to or enrollment in employer or other health coverage Employee Personally Identifiable Information Employee Applicant Name Employee Unique Employer Code Employee Home Address Employee Applicant Mailing Address Employee Applicant Birthdate Employee Social Security Number Employee Applicant Telephone Number (and type) Employee Applicant Email Employee Applicant Spoken and Written Language Preference Employee Tobacco Use Indicator and Last Date of Tobacco Use Employee Sex Employee Race and Ethnicity Category Description Employer Business Name If American Indian/Alaska Native status APTC percentage Alaskan Native: Name and amount applied Auto disenrollment information Applicant Location of Tribe Health Coverage Type (Individual or Family, if offered) Health Plan Name Applicant Address Applicant Birthdate Applicant Telephone number Applicant Email Applicant spoken and written language preference Applicant Medicaid Eligibility indicatorID Number Dental Plan Name and ID Number Other Sources of Coverage Accepting or Waiving Coverage Dependent information, start and end dates Applicant Children’s Health Insurance Program eligibility indicatorif applicable, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates Applicant CSR level Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status Contact including • Dependent Name Contact Address Contact Birthdate Contact Telephone number Contact Email Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period FFE Applicant ID FFE Member ID Gender Immigration document type and document numbers Issuer Member ID Membership in a Federally recognized tribe Net premium amount Pregnancy indicator Premium Amount, start and end dates Race/ethnicity Sex Special enrollment period reason Subscriber Indicator and relationship to subscriber • Dependent Date of Birth • Dependent Social Security Number • Dependent Relationship to Employee • Dependent Sex • Dependent Spoken and Written Language Preference • Dependent Race and Ethnicity • If American Indian/Alaskan native: Name and Location of Tribe • Dependent Tobacco Use Indicator and Last Date of Tobacco Use • If individual is living outside of home; name of individual, address, phone, e-mail address • Dependent Other Sources of Coverage • Dependent Accepting or Waiving Coverage • Special Circumstances for Employees and Dependents, i.e. marriage, moving, adopting children, losing eligibility for coverage under a group health plan or losing Employer contribution, or giving birth) Employer Offering Coverage Information Employer Name/”Doing Business As” Employer Federal Tax filing status ID Number Employer Address Business Type Category Description Employer Attestation to SHOP Eligibility Requirements Employer Contact Information Employer Contact Name and Title Employer Contact Mailing Address (tax filerif different than employer address) Employer Contact Phone Numbers (and type) Employer Contact Spoken and Written Language Preference Employer Contact Email address Employer Contact Fax Number Secondary Contact Name (optional) Secondary Contact Phone number (and type) Secondary Contact Fax Number Secondary Contact Email Address Secondary Contact Authorizations Employer Coverage Offered Employer AV Levels (Bronze, tax dependentSilver, nonGold, or Platinum) Benchmark Plan Offer of Dependent Coverage Agent/Broker/Assister/Navigator Name, Organization Name, Contact Information, FFM User ID Employer Contribution Information: • Benchmark Plan ID number-filerMedical Plan • Benchmark Plan ID number-Dental Plan • Percentage towards Employee-Medical Coverage • Percentage towards Employee Dental Coverage Category Description • Percentage towards Dependent Medical Coverage • Percentage towards Dependent Dental Coverage • Employer Offering- Single QHP or Single Metal Level • Employer Offering-Single QDP or Two QDPs Offer of Stand-alone Dental Coverage Desired Effective Date of Coverage Employee Selection Due Date Waiting Period for New Hires to Enroll Employee List, including • Employee Name • Employee Date of Birth • Employee Age • Employee Social Security Number • Employee Email Address • Employee Employment Status • Employee’s Other Coverage • Number of Dependents • Dependent information, including Dependent Name • Dependent Date of Birth • Dependent Age • Dependent Social Security Number • Dependent Email Address • Dependent’s Other Coverage Payment Method options, including • Electronic Funds Transfer Information (Checking Account Number, Routing Number) Tobacco use indicator and last date of tobacco• Credit Card information (Credit Card type, Name on Credit Card, Credit Card Number, Expiration Date, Signature, Signature Date) • Checking Information Employer Attestation to COBRA/Medicare Compliance Questions

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions tasks contemplated under this Agreement, Staff Member/ Volunteer ABE may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, Applicants, Qualified Individuals, and Enrollees, or these individuals’ legal representative or Authorized Representative, including but not limited to: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status x APTC percentage and amount applied x Auto disenrollment information x Applicant Name x Applicant Address x Applicant Birthdate x Applicant Telephone number x Applicant Email x Applicant Social Security number x Applicant spoken and written language preference x Applicant Medicaid Eligibility indicator, start and end dates x Applicant Children’s Health Insurance Program CHIP eligibility indicator, start and end dates x Applicant QHP eligibility indicator, start and end dates x Applicant APTC percentage and amount applied eligibility indicator, start and end dates x Applicant household income x Applicant Maximum APTC amount x Applicant Cost-sharing Reduction (CSR) CSRs eligibility indicator, start and end dates x Applicant CSR CSRs level x Applicant QHP eligibility status change x Applicant APTC eligibility status change x Applicant CSR CSRs eligibility status change x Applicant Initial or Annual Open Enrollment Indicator, start and end dates x Applicant Special Enrollment Period special enrollment period eligibility indicator and reason code Citizenship Status x Contact Name x Contact Address x Contact Birthdate x Contact Telephone number x Contact Email address x Contact spoken and written language preference x Enrollment group history (past six months) x Enrollment type period x FFE Applicant ID x FFE Member ID Gender Immigration document type and document numbers x Issuer Member ID Membership in a Federally recognized tribe x Net premium amount Pregnancy indicator x Premium Amount, start and end dates Race/ethnicity Sex x Credit or Debit Card Number, Name on Card x Checking account and routing number x Special enrollment period reason x Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) x Tobacco use indicator and last date of tobaccotobacco use x Custodial parent x Health coverage x American Indian/Alaska Native status and name of tribe x Marital status x Race/ethnicity x Requesting financial assistance x Responsible person x Applicant/Employee/dependent sex and name x Student status x Subscriber indicator and relationship to subscriber x Total individual responsibility amount

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions tasks contemplated under this Agreement, Staff Member/ Volunteer Web-broker may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, including Applicants, Qualified Individuals, Enrollees, Qualified Employers, and Qualified Employees including, but not limited to: i. For individual market QHP coverage: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status • APTC percentage and amount applied • Auto disenrollment information • Applicant Name name • Applicant Address address • Applicant Birthdate birthdate • Applicant Telephone telephone number • Applicant Email email • Applicant Social Security Number • Applicant spoken and written language preference • Applicant Medicaid Eligibility indicator, start and end dates • Applicant Children’s Health Insurance Program eligibility indicator, start and end dates • Applicant QHP eligibility indicator, start and end dates • Applicant APTC percentage and amount applied eligibility indicator, start and end dates • Applicant household income • Applicant Maximum maximum APTC amount • Applicant Cost-sharing Reduction (CSR) CSR eligibility indicator, start and end dates • Applicant CSR level • Applicant QHP eligibility status change • Applicant APTC eligibility status change • Applicant CSR eligibility status change • Applicant Initial or Annual Open Enrollment Indicator, start and end dates • Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status • Contact Name name • Contact Address address • Contact Birthdate birthdate • Contact Telephone telephone number • Contact Email email • Contact spoken and written language preference • Enrollment group history (past six months) • Enrollment type period • FFE Applicant ID • FFE Member ID Gender Immigration document type and document numbers • Issuer Member ID Membership in a Federally recognized tribe • Net premium amount Pregnancy indicator • Premium Amountamount, start and end dates Race/ethnicity Sex • Credit or Debit Card Number, name on card • Checking account and routing number • Special enrollment period Enrollment Period reason • Subscriber Indicator indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) • Tobacco use indicator and last date of tobaccotobacco use • Custodial parent • Health coverage • American Indian/Alaska Native status and name of tribe • Marital status • Race/ethnicity • Requesting financial assistance • Responsible person • Dependent name • Applicant/dependent sex • Student status • Subscriber indicator and relationship to subscriber • Total individual responsibility amount ii. For SHOP QHP coverage: Employee Personally Identifiable Information Employee Applicant Name Employee Unique Employer Code Employee Home Address Employee Applicant Mailing Address Employee Applicant Birthdate Employee Social Security Number Employee Applicant Telephone Number (and type) Employee Applicant Email Address Employee Applicant Spoken and Written Language Preference Employee Personally Identifiable Information (continued) Employee Tobacco Use Indicator and Last Date of Tobacco Use Employee Sex Employee Race and Ethnicity Employer Business Name If American Indian/Alaska Native: Name and Location of Tribe Health Coverage Type (Individual or Family, if offered) Health Plan Name and ID Number Dental Plan Name and ID Number Other Sources of Coverage Accepting or Waiving Coverage Dependent information, if applicable, including • Dependent Name • Dependent Date of Birth • Dependent Social Security Number • Dependent Relationship to Employee • Dependent Sex • Dependent Spoken and Written Language Preference • Dependent Race and Ethnicity • If American Indian/Alaska Native: Name and Location of Tribe • Dependent Tobacco Use Indicator and Last Date of Tobacco Use • If individual is living outside of home; name of individual, address, phone, e-mail address • Dependent Other Sources of Coverage • Dependent Accepting or Waiving Coverage • Special Circumstances for Employees and Dependents, i.e., marriage, moving, adopting children, losing eligibility for coverage under a group health plan or losing Employer contribution, or giving birth Employer Offering Coverage Information Employer Name/“Doing Business As” Employer Federal Tax ID Number Employer Address Business Type Employer Attestation to SHOP Eligibility Requirements Employer Contact Information Employer Contact Name and Title Employer Contact Mailing Address (if different than employer address) Employer Contact Phone Numbers (and type) Employer Contact Spoken and Written Language Preference Employer Contact Email Address Employer Contact Fax Number Employer Offering Coverage Information (continued) Secondary Contact Name (optional) Secondary Contact Phone number (and type) Secondary Contact Fax Number Secondary Contact Email Address Secondary Contact Authorizations Employer Coverage Offered Employer-selected AV Levels (Bronze, Silver, Gold, or Platinum) Benchmark Plan Offer of Dependent Coverage Agent/Broker/Assister/Navigator Name, Organization Name, Contact Information, FFM User ID Employer Contribution Information: • Benchmark Plan ID number-Medical Plan • Benchmark Plan ID number-Dental Plan • Percentage towards Employee-Medical Coverage • Percentage towards Employee Dental Coverage • Percentage towards Dependent Medical Coverage • Percentage towards Dependent Dental Coverage • Employer Offering-Single QHP or Single Metal Level or Single Issuer • Employer Offering-Single Stand-alone Dental Plan (“SADP”) or multiple SADPs Offer of Stand-alone Dental Coverage Desired Effective Date of Coverage Employee Selection Due Date Waiting Period for New Hires to Enroll Employee List, including • Employee Name • Employee Date of Birth • Employee Age • Employee Social Security Number • Employee Email Address • Employee Employment Status • Employee’s Other Coverage • Number of Dependents • Dependent information, including Dependent Name • Dependent Date of Birth • Dependent Age • Dependent Social Security Number • Dependent Email Address • Dependent’s Other Coverage Employer Offering Coverage Information (continued) Payment Method options, including • Electronic Funds Transfer Information (Checking Account Number, Routing Number) • Credit Card information (Credit Card type, Name on Credit Card, Credit Card Number, Expiration Date, Signature, Signature Date) • Checking Information Employer Attestation to Consolidated Omnibus Budget Reconciliation Act (“COBRA”)/Medicare Compliance Questions

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions under this Agreement, Staff Member/ Volunteer may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, including but not limited to: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status APTC percentage and amount applied Auto disenrollment information Applicant Name Applicant Address Applicant Birthdate Applicant Telephone number Applicant Email Applicant spoken and written language preference Applicant Medicaid Eligibility indicator, start and end dates Applicant Children’s Health Insurance Program eligibility indicator, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates Applicant CSR level Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status Contact Name Contact Address Contact Birthdate Contact Telephone number Contact Email Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period FFE Applicant ID FFE Member ID Gender Immigration document type and document numbers Issuer Member ID Membership in a Federally Federally-recognized tribe Net premium amount Pregnancy indicator Premium Amount, start and end dates Race/ethnicity Sex Special enrollment period reason Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filerflier) Tobacco use indicator and last date of tobacco

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions tasks contemplated under this Agreement, Staff Member/ Volunteer CDO, may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, including but not limited to: Access to Applicants, Qualified Individuals, Enrollees, Qualified Employees, and Qualified Employers, and/or these individuals’ legal representative(s) or enrollment in employer or other health coverage American Indian/Alaska Native status Authorized Representative(s): APTC percentage and amount applied Auto disenrollment information Applicant Name Applicant Address Applicant Birthdate Applicant Telephone number Applicant Email Applicant spoken and written language preference Applicant Medicaid Eligibility indicator, start and end dates Applicant Children’s Health Insurance Program eligibility indicator, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates Applicant CSR level Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status Contact Name Contact Address Contact Birthdate Contact Telephone number Contact Email Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period FFE Applicant ID FFE Member ID Gender Immigration document type and document numbers Issuer Member ID Membership in a Federally recognized tribe Net premium amount Pregnancy indicator Premium Amount, start and end dates Race/ethnicity Sex Pregnancy indicator Special enrollment period reason Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) Tobacco use indicator and last date of tobacco

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions tasks contemplated under this Agreement, Staff Member/ Volunteer XXX may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, Applicants, Qualified Individuals, and Enrollees, or these individuals’ legal representative or Authorized Representative, including but not limited to: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status • APTC percentage and amount applied • Auto disenrollment information • Applicant Name • Applicant Address • Applicant Birthdate • Applicant Telephone number • Applicant Email • Applicant Social Security number • Applicant spoken and written language preference • Applicant Medicaid Eligibility indicator, start and end dates • Applicant Children’s Health Insurance Program CHIP eligibility indicator, start and end dates • Applicant QHP eligibility indicator, start and end dates • Applicant APTC percentage and amount applied eligibility indicator, start and end dates • Applicant household income • Applicant Maximum APTC amount • Applicant Cost-sharing Reduction (CSR) CSRs eligibility indicator, start and end dates • Applicant CSR CSRs level • Applicant QHP eligibility status change • Applicant APTC eligibility status change • Applicant CSR CSRs eligibility status change • Applicant Initial or Annual Open Enrollment Indicator, start and end dates • Applicant Special Enrollment Period special enrollment period eligibility indicator and reason code Citizenship Status • Contact Name • Contact Address • Contact Birthdate • Contact Telephone number • Contact Email address • Contact spoken and written language preference • Enrollment group history (past six months) • Enrollment type period • FFE Applicant ID • FFE Member ID Gender Immigration document type and document numbers • Issuer Member ID Membership in a Federally recognized tribe • Net premium amount Pregnancy indicator • Premium Amount, start and end dates Race/ethnicity Sex • Credit or Debit Card Number, Name on Card • Checking account and routing number • Special enrollment period reason • Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) • Tobacco use indicator and last date of tobaccotobacco use • Custodial parent • Health coverage • American Indian/Alaska Native status and name of tribe • Marital status • Race/ethnicity • Requesting financial assistance • Responsible person • Applicant/Employee/dependent sex and name • Student status • Subscriber indicator and relationship to subscriber • Total individual responsibility amount

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions tasks contemplated under this Agreement, Staff Member/ Volunteer may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, including but not limited to: Access to Applicants, Qualified Individuals, Enrollees, Qualified Employees, Qualified Employers, or enrollment in employer these individuals’ legal representative(s) or other health coverage American Indian/Alaska Native status Authorized Representative(s): APTC percentage and amount applied Auto disenrollment information Applicant Name Applicant Address Applicant Birthdate Applicant Telephone number Applicant Email Applicant spoken and written language preference Applicant Medicaid Eligibility indicator, start and end dates Applicant Children’s Health Insurance Program eligibility indicator, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates Applicant CSR level Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status Contact Name Contact Address Contact Birthdate Contact Telephone number Contact Email Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period FFE Applicant ID FFE Member ID Gender Immigration document type and document numbers Issuer Member ID Membership in a Federally recognized tribe Net premium amount Pregnancy indicator Premium Amount, start and end dates Race/ethnicity Sex Special enrollment period reason Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) Tobacco use indicator and last date of tobacco

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions under this Agreement, Staff Member/ Volunteer CDO, may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, including but not limited to: to:‌ Access to or enrollment in employer or other health coverage American Indian/Alaska Native status status‌ APTC percentage and amount applied Auto disenrollment information Applicant Name Name‌‌ Applicant Address Applicant Birthdate Birthdate‌ Applicant Telephone number Applicant Email Email‌ Applicant spoken and written language preference Applicant Medicaid Eligibility indicator, start and end dates dates‌ Applicant Children’s Health Insurance Program eligibility indicator, start and end dates Applicant QHP eligibility indicator, start and end dates Applicant APTC percentage and amount applied eligibility indicator, start and end dates Applicant household income Applicant Maximum APTC amount amount‌ Applicant Cost-sharing Reduction (CSR) eligibility indicator, start and end dates Applicant CSR level level‌ Applicant QHP eligibility status change Applicant APTC eligibility status change Applicant CSR eligibility status change change‌ Applicant Initial or Annual Open Enrollment Indicator, start and end dates Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status status‌‌ Contact Name Contact Address Contact Birthdate Birthdate‌‌ Contact Telephone number Contact Email Email‌ Contact spoken and written language preference Enrollment group history (past six months) Enrollment type period period‌‌ FFE Applicant ID FFE Member ID Gender Gender‌‌ Immigration document type and document numbers Issuer Member ID ID‌ Membership in a Federally recognized tribe Net premium amount Pregnancy indicator amount‌ Premium Amount, start and end dates Pregnancy indicator‌ Race/ethnicity Sex Sex‌ Special enrollment period reason Subscriber Indicator and relationship to subscriber Social Security Number Number‌ Tax filing status (tax filer, tax dependent, non-filer) Tobacco use indicator and last date of tobaccotobacco‌

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions tasks contemplated under this Agreement, Staff Member/ Volunteer EDE Entity may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, including Applicants, Qualified Individuals, or Enrollees, including, but not limited to: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status • APTC percentage and amount applied • Auto disenrollment information • Applicant Name name • Applicant Address address • Applicant Birthdate birthdate • Applicant Telephone telephone number • Applicant Email email • Applicant Social Security Number • Applicant spoken and written language preference • Applicant Medicaid Eligibility indicator, start and end dates • Applicant Children’s Health Insurance Program eligibility indicator, start and end dates • Applicant QHP eligibility indicator, start and end dates • Applicant APTC percentage and amount applied eligibility indicator, start and end dates • Applicant household income • Applicant Maximum maximum APTC amount • Applicant Cost-sharing Reduction (CSR) CSR eligibility indicator, start and end dates • Applicant CSR level • Applicant QHP eligibility status change • Applicant APTC eligibility status change • Applicant CSR eligibility status change • Applicant Initial or Annual Open Enrollment Indicator, start and end dates • Applicant Special Enrollment Period (“SEP”) eligibility indicator and reason code Citizenship Status • Contact Name name • Contact Address address • Contact Birthdate birthdate • Contact Telephone telephone number • Contact Email email • Contact spoken and written language preference • Enrollment group history (past six months) • Enrollment type period • FFE Applicant ID • FFE Member ID Gender Immigration document type and document numbers • Issuer Member ID Membership in a Federally recognized tribe • Net premium amount Pregnancy indicator • Premium Amountamount, start and end dates Race/ethnicity Sex Special enrollment period • Credit or Debit Card Number, name on card • Checking account and routing number • SEP reason • Subscriber Indicator indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) • Tobacco use indicator and last date of tobaccotobacco use • Custodial parent • Health coverage • American Indian/Alaska Native status and name of tribe • Marital status • Race/ethnicity • Requesting financial assistance • Responsible person • Dependent name • Applicant/dependent sex • Student status • Subscriber indicator and relationship to subscriber • Total individual responsibility amount • Immigration status • Immigration document number • Naturalization document number

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions tasks contemplated under this Agreement, Staff Member/ Volunteer XXX may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, Applicants, Qualified Individuals, and Enrollees, or these individuals’ legal representative or Authorized Representative, including but not limited to: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status • APTC percentage and amount applied • Auto disenrollment information • Applicant Name • Applicant Address • Applicant Birthdate • Applicant Telephone number • Applicant Email • Applicant Social Security Number • Applicant spoken and written language preference • Applicant Medicaid Eligibility indicator, start and end dates • Applicant Children’s Health Insurance Program CHIP eligibility indicator, start and end dates • Applicant QHP eligibility indicator, start and end dates • Applicant APTC percentage and amount applied eligibility indicator, start and end dates • Applicant household income • Applicant Maximum APTC amount • Applicant Cost-sharing Reduction (CSR) CSR eligibility indicator, start and end dates • Applicant CSR level • Applicant QHP eligibility status change • Applicant APTC eligibility status change • Applicant CSR eligibility status change • Applicant Initial or Annual Open Enrollment Indicator, start and end dates • Applicant Special Enrollment Period eligibility indicator and reason code Citizenship Status • Contact Name • Contact Address • Contact Birthdate • Contact Telephone number • Contact Email • Contact spoken and written language preference • Enrollment group history (past six months) • Enrollment type period • FFE Applicant ID • FFE Member ID Gender Immigration document type and document numbers • Issuer Member ID Membership in a Federally recognized tribe • Net premium amount Pregnancy indicator • Premium Amount, start and end dates Race/ethnicity Sex • Credit or Debit Card Number, Name on Card • Checking account and routing number • Special enrollment period reason • Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) • Tobacco use indicator and last date of tobaccotobacco use • Custodial parent • Health coverage • American Indian/Alaska Native status and name of tribe • Marital status • Race/ethnicity • Requesting financial assistance • Responsible person • Applicant/Employee/dependent sex name • Student status • Subscriber indicator and relationship to subscriber • Total individual responsibility amount

PII Received. Subject to the terms and conditions of this Agreement and applicable laws, in performing the Authorized Functions tasks contemplated under this Agreement, Staff Member/ Volunteer ABE may create, collect, disclose, access, maintain, store, and use the following data and PII from Consumers, Applicants, Qualified Individuals, and Enrollees, or these individuals’ legal representative or Authorized Representative, including but not limited to: Access to or enrollment in employer or other health coverage American Indian/Alaska Native status • APTC percentage and amount applied • Auto disenrollment information • Applicant Name • Applicant Address • Applicant Birthdate • Applicant Telephone number • Applicant Email • Applicant Social Security number • Applicant spoken and written language preference • Applicant Medicaid Eligibility indicator, start and end dates • Applicant Children’s Health Insurance Program CHIP eligibility indicator, start and end dates • Applicant QHP eligibility indicator, start and end dates • Applicant APTC percentage and amount applied eligibility indicator, start and end dates • Applicant household income • Applicant Maximum APTC amount • Applicant Cost-sharing Reduction (CSR) CSRs eligibility indicator, start and end dates • Applicant CSR CSRs level • Applicant QHP eligibility status change • Applicant APTC eligibility status change • Applicant CSR CSRs eligibility status change • Applicant Initial or Annual Open Enrollment Indicator, start and end dates • Applicant Special Enrollment Period special enrollment period eligibility indicator and reason code Citizenship Status • Contact Name • Contact Address • Contact Birthdate • Contact Telephone number • Contact Email address • Contact spoken and written language preference • Enrollment group history (past six months) • Enrollment type period • FFE Applicant ID • FFE Member ID Gender Immigration document type and document numbers • Issuer Member ID Membership in a Federally recognized tribe • Net premium amount Pregnancy indicator • Premium Amount, start and end dates Race/ethnicity Sex • Credit or Debit Card Number, Name on Card • Checking account and routing number • Special enrollment period reason • Subscriber Indicator and relationship to subscriber Social Security Number Tax filing status (tax filer, tax dependent, non-filer) • Tobacco use indicator and last date of tobaccotobacco use • Custodial parent • Health coverage • American Indian/Alaska Native status and name of tribe • Marital status • Race/ethnicity • Requesting financial assistance • Responsible person • Applicant/Employee/dependent sex and name • Student status • Subscriber indicator and relationship to subscriber • Total individual responsibility amount