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First Name *

Last Name *

Phone *

Email *

Date of birth *

Applicant Social Security Number *

Applicant Household Income *

Address

Street Address *

City

State

Country

Postal code

Employment Type *

Unemployment

1099

Self Employed

Are You Married? *

Yes

Do You Have Any Dependents?

Yes

(If Applicable) List Dependents + Date of Birth: *

List Any Current Doctors and Medications You Need Covered: *

My job is to secure you the most benefits for the most affordable cost, that said, what is a reasonable budget to cover everyone that needs health insurance? * *

Additional Comments/Questions?

Consent Signature *

Clear

By Checking this box and signing this form, I hereby give my permission to The Salems LLC Licensed Insurance Agents (NPN 20570780, 21303735), as mentioned in this agreement, to serve as the health insurance agent or broker for myself and my entire household, if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize and its affiliates to: View and use the confidential information provided by me in writing, electronically, or by telephone for the purposes of: Searching for an existing Marketplace application. I consent to receiving automated phone calls, SMS, and email messages using templated messages or Artificial Intelligence (AI) to help collect information or communicate with me. Standard message and data rates may apply, messaging frequency varies, and consent is not a condition of purchase. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs. Providing ongoing account maintenance and enrollment assistance, as necessary. Responding to inquiries from the Marketplace regarding my application. Act as my Agent of Record concerning all matters related to my health insurance. This designation allows and its affiliates to represent and assist me in all interactions with the health insurance provider. Ensure that my Personally Identifiable Information (PII) is kept private and safe when collecting, storing, and using it for the above purposes. and its affiliates commit to not sharing my PII for any purposes other than those explicitly stated in this agreement. I further attest to one or more of the following conditions being true: My income meets the minimum required to qualify for subsidized healthcare under the Federally Facilitated Marketplace. I, or someone in my household, have experienced a qualifying life change in the past 60 days that qualifies for a Special Enrollment Period. I, or someone in my household, either lost qualifying health coverage in the past 60 days or expect to lose coverage in the next 60 days.

Scope of Appointment: I appoint , The Salems LLC Licensed Insurance Agents (NPN 20570780, 21303735) as my representative for up to 10 years for the above mentioned purposes. I grant the parties mentioned to contact me via phone, email, and/or text. Revocation: I understand that my consent remains in effect until I revoke it. I may revoke or modify my consent at any time by contacting The Salems LLC Insurance Agents (NPN 20570780, 21303735) and its affiliates at [email protected], [email protected] , 602-228-3535: Reply PAUSE to opt-out and unsubscribe from SMS messages.

I consent to allow my new Agent of Record (AOR) to send letters, emails, and phone calls on my behalf for the purpose of contacting and revoking any previous AOR from accessing my private information or attempting to change AOR or plans without my express verbal and signed consent.

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