Sales Enrollment Consent Signature Page | The "REAL" Insurance Lady

PREQUALIFY NOW

The “REAL” Insurance Lady

THE NATION'S #1 OBAMACARE-PRODUCING AGENCY

PREQUALIFY NOW

THE "REAL" INSURANCE LADY ENROLLMENT CONSENT FORM

First Name

Last Name

Birthday

Customer Status

Client Prospect

ID #

Consenting Statement:
I give my permission to The “REAL” Insurance Lady Agency, LLC and its agents to serve as the health insurance agent or broker for myself and my entire household if applicable, By consenting to this agreement, I authorize The “REAL” Insurance Lady Agency, LLC to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: Searching for an existing Marketplace application; Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums; Providing ongoing account maintenance and enrollment assistance, as necessary; or Responding to inquiries from the Marketplace regarding my Marketplace application.

I understand that The “REAL” Insurance Lady Agency, LLC will not use or share my personally identifiable information (PII) for purposes other than those listed above. The “REAL” Insurance Lady Agency, LLC will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I acknowledge, understand, and agree that my 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 5760 Cullen Blvd, Houston, TX 77021.

Submitted By:

Signature