I hereby wish to appoint VIVID multiservices LLC as my insurance agent at Record.

For the requested effective date (year 2024) for the lines of insurance shown above and in effect. This form will supersede any authorizations for the lines of business listed and remove any Producer, currently designated on my policies.

By signing this form, I authorize my agent to access, collect, and record my personal protected health and personal health information (PHI), which must be safeguarded and protected by all means possible, with a 10-year deadline related to the lines of business described above, including, but not limited to:

Conduct personal online searches to help me complete eligibility applications to help me select and enroll health plans and other insurance products.

Assist with plan selection, applications, down payments, monthly payments, and uploading required documents.

Assist with life changes such as my address, household information, income, or any other means necessary to keep informed and obtain services related to the lines of business described above and other content that may be of interest to me.

In addition, by signing this form physically or electronically, I authorize this consent to be indefinite, unless I (the client) revoke such authorization:

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