New & Returning Client Consent & Update Form
This form is required in order keep ongoing agent assistance
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
For returning clients/insured
For returning enrollees, do you have any household changes from November 1, 2022 i.e ( Address, Income, Family size, Income, Marital status, Employment changes etc...)???
Select one
Yes, please update
No, everything is the same
If you answered yes above, please provide details of household changes
Required Consent
By submitting this form on today’s date(time stamped), I(Name Noted Above) authorized my Agent(Marcus Williams 17403853) to provide ongoing assistance for me and my household(if applicable) to obtain and maintain a qualified health plan on the Federal Facilitated Marketplace. I understand that I can rescind this consent at anytime by contacting my agent by emailing marcus@lifeandlegacynow.com
Signature
Submit Form
Should be Empty: