First and Last Name *

Cell Phone (We Enroll You Via Text Message) *

Address *

City *

State *

Zip Code *

What Is Your Gender? *

Do You Use Tobacco Regularly? *

What Is Your Date Of Birth? *

Number of Tax Dependents You Claim On Your Taxes? *

Total Applicants Signing Up Including You? *

What Is Your Monthly Household Income? (If You Have A Spouse Include Their Income) *

I give my permission to Linda White 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. 4. Responding to inquiries from the Marketplace regarding my Marketplace application. 5. If you already have a marketplace plan, you give permission to switch you to a better plan if one is available, if you are already on the best plan possible you are requesting Sean Schickel to take over as your agent of record from this point forward unless notified of a change. 6. I agree that if I am making less than 100% of the federal poverty line that I am looking for work making at least minimum wage.

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 sending an email, text, or phone call to:

Name of Primary Writing Agent: Linda White

Agent National Producer Number: 19505913

Phone Number: (800) 775-9072

Email Address: [email protected]

Please Provide Signature Below *

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