Primary First Name

Primary Last Name

Primary Email

Primary Cell Phone Number

Address

City

State

Zip Code

Primary Date of Birth MM-DD-YYYY

Primary Social Security Number XXX-XX-XXXX

Will Your Spouse Be Applying For Coverage

Spouse First Name

Spouse Last Name

Spouse Phone Number

Spouse Email

Spouse Date of Birth

Spouse Social Security Number

Will You Be Enrolling Children?

Child 1 First Name

Child 1 Last Name

Child 1 Date of Birth

Child 1 Social Security Number

Child 2 First Name

Child 2 Last Name

Child 2 Date of Birth

Child 2 Social Security Number

Child 3 First Name

Child 3 Last Name

Child 3 Date of Birth

Child 3 Social Security Number

I give my permission to Scott Vance 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 the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: 1. Searching for an existing Marketplace application; 2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums; 3. Providing ongoing account maintenance and enrollment assistance, as necessary; or 4. Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by email to scott@vigrp.com or in writing to Vance Insurance Group -- PO Box 5046, Sanford, NC 27331 Scott Vance Writing Agent: Agent National Producer Number 6617587: Phone Number: 910-818-2466 Email Address: scott@vigrp.com

I Accept