YOU'RE 1-STEP AWAY FROM CLAIMING YOUR

$500 VISA CARD

FILL OUT YOUR DETAILS BELOW TO RECEIVE YOUR $500 VISA CARD IN THE MAIL!

What is your address where we can mail the cards? *

Address
City
State

Primary Applicant Information *

Primary Applicant's Date of Birth MM/DD/YYYY
Primary Applicant's Social Security Number

Do you have a spouse? *

Yes

Spouse Information *

Spouse's Legal First Name
Spouse's Legal Last Name
Spouse's Date of Birth MM/DD/YYYY

Do you want to enroll your spouse? *

Yes

Do you have tax dependents?

Yes

Dependent Information 1-9 When done skip to next step for your $500 Visa Card!

Dependent 1 Full Legal Name
Dependent 1 Date of Birth MM/DD/YYYY
Dependent 2 Full Legal Name
Dependent 2 Date of Birth MM/DD/YYYY
Dependent 3 Full Legal Name
Dependent 3 Date of Birth MM/DD/YYYY
Dependent 4 Full Legal Name
Dependent 4 Date of Birth MM/DD/YYYY
Dependent 5 Full Legal Name
Dependent 5 Date of Birth MM/DD/YYYY
Dependent 6 Full Legal Name
Dependent 6 Date of Birth MM/DD/YYYY
Dependent 7 Full Legal Name
Dependent 7 Date of Birth MM/DD/YYYY
Dependent 8 Full Legal Name
Dependent 8 Date of Birth MM/DD/YYYY
Dependent 9 Full Legal Name
Dependent 9 Date of Birth MM/DD/YYYY

I agree that I have read this attestation and I give my permission to LDR Insurance Agency, NPN: 21032229, to serve as my broker for myself and my household, for the purpose of enrollment in a qualified Health Plan offered by the Federally Facilitated Marketplace. I consent to allow the above mentioned agent to view and use my confidential information for the following purposes: 1. Search for an existing Marketplace Plan; 2. Complete an application for eligibility and enrollment in a Marketplace Plan; 3. Provide ongoing maintenance and enrollment assistance; or 4. Respond to inquiries from the Marketplace regarding my application. I confirm what I have shared is accurate and true for entry on my Marketplace Health Insurance Application, that I have read and consent with the terms and understand the above mentioned agent will safely store and use my personal identifiable information for the above stated purposes, and by submitting this document I agree that my household income falls within the chart below, that I do not have edicare/Medicaid/Employer Coverage, and I do not use tobacco products, qualifying myself for Zero Premium Health Coverage. I understand my consent remains until I revoke it by emailing blubaits@gmail.com. By providing your mobile number, you consent to receive SMS communications from LDR Insurance Angency. I can opt out of texts any time by replying "STOP".

Authorization Date *

Authorization Signature - I authorize you to be my Agent of Record each month until I revoke my consent and re-enroll me in the best plan during Open Enrollment if my current plan is discontinued. *

Clear

YOU'RE 1-STEP AWAY FROM CLAIMING YOUR

$500 VISA CARD

🔒YOUR INFORMATION IS 100% SAFE. I UNDERSTAND THAT MY CONSENT IS NOT A CONDITION TO PURCHASE ANYTHING.

$0 Health Insurance

© All Rights Reserved. LDR Insurance Agency.