Consent – Lionyx Insurance

Name

First

Last

Birthdate

Sample : MM/DD/YYYY

zip code

Email

Phone

You must agree to the following terms before you click submit *

I understand that by clicking submit below, I am attesting that the information provided is true and correct to the best of my abilities.

I understand that by clicking submit below, that I am authorizing this broker, Shamsieh Jahangiri NPN: 18708768, to be listed as the broker of record on my Marketplace account.

I understand that by giving this authorization, I consent to have the broker, Shamsieh Jahangiri NPN: 18708768, access my data within my states designated exchange.

I understand that I may revoke access by request at ANY time directly with the Exchange without cause OR by emailing my request to my broker.

Signature

Type full legal name