Verify Your Marketplace Application Information

I authorize Billy Jordan Jr. or his designated assignee from The Jordan Insurance Agency, LLC (NPN 16920510) to be my health insurance broker for myself and my household on the Federally Facilitated Marketplace. They may access and use my confidential information for tasks such as searching for existing Marketplace applications, completing eligibility and enrollment applications, providing account maintenance, and responding to Marketplace inquiries. I confirm the accuracy of my application information and understand that my personal data will be used solely for these purposes. I can revoke or modify this consent by certified letter or email at any time. I have reviewed my eligibility application information.

I confirm it to be accurate in compliance with § 155.227. This includes, but is not limited to, information related to my contact profile (email, phone, and address) as well as my income reported to the exchange.

I am signing this application under penalty of perjury, which means I have provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.

Agency Contact Information:

The Jordan Insurance Agency, LLC

Phone: 980.448.7007

Address: 13925 Ballantyne Corporate Place Suite 425, Charlotte, NC 28277

Agent Point of Contact: Billy Jordan (NPN 8699876)