Contact Consent Authorization

Contact Consent Authorization

Review the consent terms, confirm the checkbox, and sign to authorize contact about health insurance options.
My referring agent was:

First NameLast Name
Full Name

First NameLast Name
Telephone Number(s)
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
By checking the box and signing below, I authorize Valor Insurance Partners LLC ("Valor") and its licensed agents to contact me at the telephone number(s) and email address I provided above, for the purpose of marketing and discussing health insurance products, including:
I specifically authorize Valor to contact me using:
I understand and agree that:

1. This consent covers marketing calls/texts to my wireless number. I am giving permission to receive telemarketing calls and texts, including those made with an autodialer or prerecorded/AI voice, to the specific number(s) I provided, even if that number is a cell phone and even if I am charged for the call or text.

2. My signature here is not required to buy anything. Agreeing to this is not a condition of purchasing any insurance product or service from Valor.

3. Do Not Call registries. I understand that this consent authorizes Valor Insurance Partners LLC to contact me at the telephone number identified above as described in this consent, even if that number is listed on the National Do Not Call Registry or an applicable state Do Not Call list.

4. Message and data rates may apply; frequency varies. Reply STOP to any text to opt out, or HELP for help.

5. I can revoke this consent at any time by any reasonable method, including replying STOP to a text, telling an agent directly, clicking unsubscribe, emailing privacy@valorinsurancepartners.com, or calling 727-546-0302. Revoking will not affect any coverage I already have.

6. This consent is valid for 12 months from the date signed, unless I revoke it sooner or renew it.

7. This is not a scope of appointment or enrollment. A separate scope of appointment will be completed before any Medicare sales meeting, and this form does not enroll me in any plan.

8. Medicare disclosure: We do not offer every plan available in your area. Any information provided is limited to the plans we do offer. Contact Medicare.gov or 1-800-MEDICARE (TTY 1-877-486-2048) for information on all your options.

9. Electronic signature. I agree my e-signature is legally binding under the E-SIGN Act and Florida's UETA, and I may request a paper copy at referrals@valorinsurancepartners.com.
I have read this Prior Express Written Consent and I agree.
Signature
Date and Time Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Should be Empty: