MEDLIT INSURANCE

SELF ENROLLMENT FORM

*By signing up, you agree to the following: You agree that you don’t have other health insurance coverage elsewhere, to the best of your knowledge. You also agree that we will put you on the best free plan available in your area. If a free plan doesn’t exist for your situation, then the insurance company will send you a bill. You are not obligated to pay the bill if you do not want health insurance. You agree that we can send automated text messages, emails, or voice recordings to notify you if anything is needed on your account. You agree that you have given us permission to apply for health insurance and advanced premium tax credits using the federal or state health insurance marketplace. You agree that your information supplied on the application is accurate to the best of your knowledge. You agree that you allow your agent, or an employee that works for your agent, to access your healthcare.gov account to help renew your coverage, respond to requests for more information, or to update items needed or requested. You agree that you are giving permission for your agent to take over as agent of record on your account, which is required to complete the above tasks, and to notify you if your account has requests for more information. If we think you have the best plan for your needs, we will take over as broker and leave you on that plan. Your completion of the web form on our website is a digital agreement to these terms.*

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