David Lowe Insurance Agency

I authorize David lowe Insurance Agency LLC to be my agent of record and to discuss any matters regarding my application for health insurance including claims. The above information is true and I alone am responsible for its accuracy. I direct its use for: establishing an account on my behalf with Healthcare.gov, to qualify for a health insurance tax credit, and to enroll in my chosen insurance plan. I plan to report this same information on my income tax return.I understand that if I am married I will have to file a joint tax return. Everything contained on this form is strictly confidential protected health information. Unautorized use is a violation of federal law.