This serves as an invitation to explore insurance options I am requesting information on (i.e., Life insurance, Medicare, Prescription Drug Plans, etc),
By submitting this form, I consent to being contacted by a licensed insurance agent for the promotion of insurance products I may be interested in.

I acknowledge that the individual contacting me for discussions on insurance products is licensed and certified.
It is understood that this person is not affiliated with or employed by the Federal government.

This form should be completed by the person seeking enrollment in a insurance plan or their authorized representative. Submitting this
form indicates my agreement to engage in a discussion with a licensed insurance agent to explore coverage with insurance products.

I know I am under no obligation to purchase anything. And I understand all consultations are offered without charge.

All information supplied on this form is confidential and will not be sold to third parties.