Marketplace Application Accuracy and Update Confirmation Laughlin Insurance

Marketplace Application Accuracy and Update Confirmation

Laughlin Insurance, Inc. 10746 NE Halsey St Portland, OR 97220 (503) 282-0827
I have reviewed the Marketplace eligibility application information and confirmed its accuracy prior to the application being submitted. Laughlin Insurance 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 Laughlin Insurance will not use or share my personally identifiable information (PII) for any purposes other than those to which I consented. Laughlin Insurance 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 Laughlin Insurance beyond what is required on the Marketplace application for eligibility and enrollment purposes.

Name of Agency: Laughlin Insurance, Inc.

Agents: Paris Laughlin, Stuart Ouellette, Rachel Laughlin, Katie Hernandez

Agency National Producer Number: #5779282

Owner of Agency: Paris Laughlin

Agency Address: 10746 NE Halsey St Portland, OR 97220

Phone: (503) 282-0827
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Please indicate the requested changes to your Marketplace application that you reviewed with your agent, and confirm your intent to have your Laughlin Insurance submit your application and enroll you in the discussed plan; *
Signature*

Powered by Jotform SignClear
Today's Date*

MonthDayYear
Date
Should be Empty: