Consent Signature Page | The "REAL" Insurance Lady

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The “REAL” Insurance Lady

THE NATION'S #1 OBAMACARE-PRODUCING AGENCY

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THE "REAL" INSURANCE LADY RENEWAL CONSENT FORM

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I authorize The "REAL" Insurance Lady Agency, LLC to complete my renewal for the upcoming Open Enrollment Season in accordance with my selection below. If my plan is no longer available for FREE during the upcoming Open Enrollment Season, I authorize The "REAL" Insurance Lady Agency, LLC to:

Option 1 - Renew me in the most similarly suitable plan available for a $0 premium. I understand that this may require me to change carriers.  Option 2 - Renew me with my current plan and carrier. I agree to pay the premium and further understand that if the premium is not paid before the Effective Date, I will be enrolled in the plan described in Option 1 to insure that I remain covered.

I acknowledge, understand, and agree that my renewal consent remains valid until revoked, and that I may revoke or modify my consent at any time by sending a written letter to The “REAL” Insurance Lady Agency, LLC, 2612 Riverside Dr. Houston, TX 77004.

By signing this form:

1. I give explicit consent to The "REAL" Insurance Lady Agency, LLC to perform all duties and functions related to my enrollment, eligibility applications, plan selection and ongoing account and enrollment maintenance.

2. I have reviewed the eligibility information provided by me to TRIL and confirm that the information is true and accurate to the best of my knowledge.

3. I acknowledge that The "REAL" Insurance Lady Agency, LLC will be using information previously provided by me to process my renewal, and I agree to report any changes to income, household, contact info or offers of insurance.