Life Insure Coverage
First Name* Last Name* Phone* A-Number Email* DOB City State Postal code Social Security Please enter your Projected Annual Household Income for 2023* Who referred you? (If no one please ignore this form field)
I give Life Insure Coverage permission to act as my household's and my personal health insurance agent. As a result, Life Insure Coverage is able to sign up me and my family for a Qualified Health Plan through the Federally Facilitated Marketplace. By agreeing to this, I agree to allow 'Life Insure Coverage' to use my private data in the ways listed below:
1. Look for a Marketplace application that is already there. 2. Submit applications for enrolment in a Marketplace plan or other government insurance programmes and verification of eligibility. 3. Offer continuing help with account upkeep and enrollment. 4. Answer the Marketplace's questions about my application. My personal information will be kept private and safe by the Agent, who will only use it as described above. I certify that, to the best of my knowledge, the data I submit on my application will be accurate. I am aware that I am under no obligation to divulge any personal information save what is necessary for the application. I can email you at any moment to revoke or change my consent. [[email protected]] I accept your offer to sign me up for the best health plan available based on your knowledge. I give you permission to enrol me in the next best plan if zero premium plans are not available. I give you permission to submit the required information through my healthcare.gov account. I attest to my comprehension of and agreement with the conditions stated in this attestation by signing below.
