3 Colo. Code Regs. § 702-1-2-17-B
Required Disclosure for Fees Charged for Assisting with the Renewal of an Individual Health Benefit Plan
[PRODUCER LETTERHEAD ALLOWED]
INSURANCE PRODUCER FEE DISCLOSURE FOR ASSISTING WITH THE RENEWAL 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 reviewing and discussing other plan options with you in an effort to provide a recommendation for an individual health benefit plan that best suits your needs.
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 renewal 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 assisting with the renewal of an on-exchange individual health benefit plan as an off-exchange individual health benefit plan.
If I am paid commission for the renewal 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 reviewing and discussing other plan options with you and assisting you in the renewal of your current individual health benefit plan will be: [DOLLAR AMOUNT].
[NAME OF PRODUCER] [NAME OF CLIENT]
[PRODUCER SIGNATURE AND DATE] [CLIENT SIGNATURE AND DATE]
3 CCR 702-1-2-17-B