I authorize and give consent for David Taylor NPN 15870969 to use my personal information and access my Market Place account for health insurance quoting, plan selection, enrollment, updating/maintenance, and or renewal purposes.
I authorize the use of my current year estimated income, future years estimated income, and other application information which I confirm to be correct, to be submitted for benefit, premium and subsidy calculations. I also authorize David Taylor to update and or maintain my application for insurance to the best of his ability for the current plan year and future plan years until changed by me in writing so that I do not loose insurance and or subsidy benefits.  I confirm that I will notify David Taylor in writing of any income, family, address, or other material changes to my application.

I confirm that apart from providing correct information, I have separately reviewed the eligibility application information with David Taylor and confirmed its accuracy prior to the application being submitted. David Taylor explained the attestations at the end of the eligibility application to me prior to the application being submitted and I was given an opportunity to ask questions about them.  This reviewal shall survive policy years and I will further review my application with David Taylor if and when I make any changes.

I affirm that no one on my application requesting insurance is on or elligible for Medicaid or Medicare. 

Applicants are responsible for all information on the insurance application and are required to provide true answers to all of the questions to the best of their knowledge. Applicants may be subject to penalties under federal law if they intentionally provide false information.

I give David Taylor permission to act as my agent for health insurance and to access my personal information for quoting and to submit my application to the market place to obtain health insurance along with any subsidies available for myself and anyone requiring and or not requiring  insurance on my application. I also give David Taylor permission to update, maintain, renew, respond to Market Place inquiries, and submit my application for insurance from time to time as needed, from today's date forward until rescinded by myself in writing to dave@coveragebydave.com.

By typing my name below, I signify that I understand, I agree, I Attest to the statments above, and that this is my electronic signature......