This form gives a certified MNsure assister the authority to create an account on MNsure.org in your name and submit an application on your behalf. It is ONLY for individuals who cannot access a computer to create an account and cannot meet in-person with an assister. Please read and complete this form carefully.

Assisters: this form must be completed and submitted by the consumer.
Consumer Information

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* 1. Consumer First Name

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* 2. Consumer Last Name

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* 3. Consumer Email Address

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* 4. Consumer Date of Birth

Date 

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* 5. Consumer Address

Privacy Warning
We are asking for this information about you so we can contact you if needed and to confirm your identity. The information you provide is private. You are not legally required to provide this information and there are no negative consequences if you do not complete this form, though your assister will be unable to create an account and apply for health coverage on your behalf. MNsure staff will have access to this information, as well as others with legal authority. MNsure will keep it for up to ten years. This privacy notice does not include the MNsure.org Terms of Use and Privacy Notice if you provide MNsure with additional information to create an account or apply for health coverage. For more information about MNsure’s Terms of Use and Privacy Warnings for MNsure participants, go to https://www.mnsure.org/resources/terms-conditions.jsp.
Account Creation
By completing and signing this form, you are authorizing your assister to create an account for you on MNsure.org because you do not have access to computer and cannot meeting in-person with an assister. Creating an account is the first step to determine your eligibility for benefits and enrolling in health coverage. To create a new account, MNsure must collect enough information to verify your identity. Your assister will ask for this information from you to enter when he or she is creating the account. Your information is private and he or she must safeguard it. When your assister is creating your account, he or she must provide a privacy warning from MNsure about the information being requested and ask if you agree to the MNsure terms and conditions. By asking an assister to create an account for you, you agree to use the system for authorized purposes only, in compliance with state and federal law, and agree to the MNsure Terms and Conditions. A copy of the privacy warning and the terms and conditions are available at www.mnsure.org/resources/terms-conditions.jsp. Your assister cannot create your account if you do not agree.

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