Sales Enrollment Consent Page | The "REAL" Insurance Lady

THE "REAL" INSURANCE LADY ENROLLMENT CONSENT FORM

10/14/2026 5:24 am

First Name

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Client's Email

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Client's ID#

Consenting Statement:
The “REAL” Insurance Lady Agency, LLC (TRIL) would like permission to help you and your household with Marketplace health coverage. By giving permission, you allow TRIL and its licensed agents to use the personal information you give us to:
• Find and open your Marketplace application
• Create or complete an application
• Check whether you may qualify for a Marketplace plan, Marketplace savings, Medicaid or CHIP
• Help you enroll in a Marketplace health plan
• Help with renewals, account updates and other enrollment needs
• Answer questions from the Marketplace about your application

TRIL will use your personal information only for these services and will protect it when it is collected, viewed, stored or used. You do not have to give us personal or health information that the Marketplace does not need.

This permission stays in place until you cancel or change it. You may cancel or change your permission by calling or texting 713-367-1161 or mailing a written request to:

The “REAL” Insurance Lady Agency, LLC 4340 Griggs Road Houston, TX 77021

This message gives TRIL permission to begin helping you. It does not approve your completed application or health plan. Before anything is submitted, a licensed agent will review your application and plan with you and ask for your final approval.

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