Marketplace Application Accuracy and Update Confirmation

Marketplace Application Accuracy and Update Confirmation

Laughlin Insurance, Inc. 10746 NE Halsey St Portland, OR 97220 (503) 282-0827
Name*

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Email*
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Phone Number*
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Please indicate the requested changes to your Marketplace application that you reviewed with your agent, or confirm your intent to have your Agent submit your application and enroll you in the discussed plan; *
I have reviewed the Marketplace eligibility application information and confirmed its accuracy prior to the application being submitted. Paris Laughlin 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. I understand that Paris Laughlin will not use or share my personally identifiable information (PII) for any purposes other than those to which I consented. Paris Laughlin will ensure that my PII is kept private and safe when creating, collecting, disclosing, accessing, maintaining, storing, and using my PII for the purposes I consented to. I understand that I do not have to share additional PII or protected health information (PHI) with Paris beyond what is required on the Marketplace application for eligibility and enrollment purposes.

Name of Primary Writing Agent: Paris Laughlin
Agent National Producer Number: 1012000
Phone Number: (503) 282-0827
Email Address:paris@laughlinagency.com
Name of Agency (if applicable): Laughlin Insurance, Inc.
Agency National Producer Number: 100159973
Owner of Agency: Paris Laughlin
Phone Number: (503) 282-0827
Email Address: paris@laughlinagency.com
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