Agent Consent Form

Customer Consent Contact Form

Find out what Life or Health insurance will cost you. Please try to complete this form in its entirety for permission to assist you. Calls will be made in the order in which the forms were submitted. Thanks for your patience in advance.
Health Insurance, Life & Credit Repair Coach

Kerry Ann Rahate, Licensed Agent
Please complete all information below:
Quote me on;*
Name*

Mr./Mrs./Ms.First NameLast Name
Date of Birth *

MonthDayYear
Date
Sex*
E-mail*
Phone*
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Years living at current residence
Life Policies only

HeightWeight
Place of Employment*
Type Independent contractor if self Employed and list type of business.
Yearly Income
*Minimum income for health 2024 is $14580 for one person to qualify for healthcare on the marketplace
Marital Status
Household members
(How many people are on your taxes)
Children
(How many children do you have?)
Additional Household members

Optional only fill this section if married, have children or other dependent in the tax household (Spouse, children & parents)
Spouse Name

First NameLast Name
DOB

MonthDayYear
Email
Phone
Email
example@example.com
Child Name

First NameLast Name
DOB

MonthDayYear
Date
Child Name

First NameLast Name
DOB

MonthDayYear
Date
Child Name

First NameLast Name
DOB

MonthDayYear
Date
Child Name

First NameLast Name
DOB

MonthDayYear
Date
How did you find me?
Referred by (Optional)

First NameLast Name
I, First Name* Last Name* give my permission to Kerry-Ann Rahate to serve as my insurance agent. I have viewed consent document and sign below giving my full consent.
Signature*

Clear
By signing this form, I hereby give my consent to Kerry-Ann Rahate and any of her affiliates to contact me and work with all insurance companies on my behalf. I understand that I may revoke consent in writing at anytime.
Should be Empty:

Customer Consent Contact Form

Health Insurance, Life & Credit Repair Coach

Additional Household members