3 Colo. Code Regs. § 702-1-2-17-A
Required Disclosure for Fees Charged for the Sale of an Individual Health Benefit Plan
[PRODUCER LETTERHEAD ALLOWED]
INSURANCE PRODUCER FEE DISCLOSURE FOR THE SALE OF AN INDIVIDUAL HEALTH BENEFIT PLAN
[The following text must be in 12 point font.]
I [PRODUCER NAME] hereby disclose to [NAME OF CLIENT] on [DATE] that I am not receiving any compensation for the individual health benefit plan you have selected.1
Subject to the penalties set forth in § 10-2-801, C.R.S., I certify, through this notice, that I do not receive commission for the sale of this individual health benefit plan from the carrier offering this individual health benefit plan. I also certify that I will charge the same fee for the sale of an on-exchange individual health benefit plan as an off-exchange individual health benefit plan.
If I am paid commission for the sale of this individual health benefit plan in the future, I agree to refund the full amount of the fee that you have paid.
I will not charge a fee for assisting in enrollment in Medicaid or the Children's Basic Health Plan.
The fee that I will charge you for the sale of an individual health benefit plan will be: [DOLLAR AMOUNT].
[NAME OF PRODUCER] [NAME OF CLIENT]
[PRODUCER SIGNATURE AND DATE] [CLIENT SIGNATURE AND DATE]
___________________________
1 Sections 10-16-133(5)(b) and 10-22-112(3)(a), C.R.S.
3 CCR 702-1-2-17-A