Home » Health Insurance Consent Form

Health Insurance Consent Form

Enrollment Consent Form : I authorize Michael Jubinville / Insure Local to act as my health insurance Agent for myself and my household as needed, for enrollment in a Qualified Health Plan on the Federally Facilitated Marketplace. This includes accessing and using my confidential information solely for purposes such as application completion, account maintenance, and responding to Marketplace inquiries. I understand my information will be kept secure and used only for these purposes. I confirm the accuracy of the information provided and can revoke or modify this consent at any time by contacting my Agent.

Primary Writing Agent: Michael Jubinville
Agent National Producer Number: 19439022
Phone number: 901-591-7912
Email address: [email protected]
Name of Agency: Insure Local
MM slash DD slash YYYY
MM slash DD slash YYYY

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

©2024. All rights reserved. | Powered by Zywave Websites