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*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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. Stuart Ouellette 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 Stuart Ouellette will not use or share my personally identifiable information (PII) for any purposes other than those to which I consented. Stuart Ouellette 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 Stuart beyond what is required on the Marketplace
application for eligibility and enrollment purposes.

Name of Primary Writng Agent: Stuart Ouellette
Agent National Producer Number: 3468051
Phone Number: (503) 282-0827
Email Address: stuart@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
Signature*
Todays Date*

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