Please Review and Sign Below

Please carefully review the application disclosures for Colin Logue related to your application for Health Insurance. 

Privacy Notice and PII Consumer Consent
Advance Premium Tax Credit Disclosure
Agent of Record Letter:
Cigna
SelctHealth
U of U Health Plans
Other Carriers
Marketplace Representation and Authorization
Terms, Conditions & Disclosure of Information

After signing and submitting this form, your agent will contact you to complete and submit the application for the requested policy and provide a quote for any supplemental products. This is neither a guaranty of coverage or benefits. Actual plan benefits to be determined by the insurance carrier upon approval and acceptance.

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Signature:

Dry Woods

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