Please Complete All Fields

Please correct the errors described below.
IF MARRIED - YOU MUST FILE JOINT TAX RETURN
FULL LEGAL NAME, DATE OF BIRTH, SOCIAL SEC #, RELATIONSHIP TO PRIMARY (ex: JOHN DOE, SELF, 1/1/1970, 123456789
EVEN IF NOT NEEDING COVERAGE (NEEDED FOR SUBSIDY)
(NAME ONLY)
(WHERE EMPLOYED FOR ALL?)
(CURRENT YEAR)
TO EMPLOYEE OR DEPENDANTS/FAMILY
I, (Client), authorize Toby D Oliver to assist me, my spouse and/or dependents if applicable, with Marketplace transactions and to make updates to my Marketplace application and/or policy based upon information provided by me. I acknowledge that I am solely responsible for the accuracy and truthfulness of the information I provide. Further, I acknowledge that the Agent has informed me of the functions and responsibilities that apply to Agent's role in the Marketplace. Agent Phone: 8289630587 Agent Email: tobyoliverhealth@gmail.com This consent will remain in effect until revoked by me in writing by contacting the agent directly.

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