Agent Consent Form

Client Consent Form

Find out what Life or Health insurance will cost you. Please complete this form in full to obtain permission to assist you. Calls will be made in the order in which the forms were submitted.
Health & Life Insurance

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

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
E-mail
Phone
Format: (000) 000-0000.
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
Marital Status
Household members
(How many people are on your taxes or listed as your dependents including you)
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
2 digit month, 2 digit day, 4 digit year
Email
Phone
Email
example@example.com
Child Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I, First Name* Last Name* give my permission to Kerry-Ann Rahate to serve as my insurance agent. I have viewed the consent document and signed below, giving my full consent to her and her assigned agent or affiliated partner.
Signature

By signing this form, I hereby give my consent to Kerry-Ann Rahate and any of her affiliates to contact me and work as my insurance agent. I understand that I may revoke consent in writing at anytime.
How did you find me?
Referred by (Optional)

First NameLast Name
Should be Empty:

Client Consent Form

Health & Life Insurance

Additional Household members