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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.

1438 Wildwood Court Grass Lake, MI
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