Permission to Contact

This form documents your express consent under the Telephone Consumer Protection Act (TCPA) and related state laws for the licensed agent named below to contact you about the topics you select, using the channels you select. Your consent is voluntary, is not a condition of any purchase, and may be revoked at any time.

Contact Channels

Phone call (live or recorded)

Text message (SMS/MMS). Message and data rates may apply.

Email at the address on file

Topics

Medicare plans (Advantage, Supplement, Part D)

Health insurance (ACA / marketplace, employer alternatives)

Other insurance products (dental, vision, life, annuity, etc.)

Electronic Signature

Full Legal Name

I consent to using electronic signatures and understand this has the same legal effect as a handwritten signature.

I give my express written consent to be contacted using the channels and about the topics selected above.

I confirm my identity and authorize this electronic signature to be legally binding.

Complete Signature