Marketplace Application Accuracy and Update Confirmation Katie Hernandez

Marketplace Application Accuracy and Update Confirmation

Laughlin Insurance, Inc. 10746 NE Halsey St Portland, OR 97220 (503) 282-0827
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Please indicate the requested changes to your Marketplace application that you reviewed with your agent, and confirm your intent to have your Agent submit your application and enroll you in the discussed plan; *
I have reviewed the Marketplace eligibility application informati on and confirmed its accuracy prior to the application being submitted. Katie Hernandez 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 Katie Hernandez will not use or share my personally identifiable information (PII) for any purposes other than those to which I consented. Katie Hernandez 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 Katie Hernandez beyond what is required on the Marketplace application for eligibility and enrollment purposes.

Name of Primary Writing Agent: Katie Hernandez
Agent National Producer Number: 20139043
Phone Number: (503) 282-0827
Email Address: katie@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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