Today’s date is 07-06-2025. My name is . My Date of Birth is . In order to assist me as best as possible, I provide consent to licensed agent Harona Osborne to access the marketplace on my behalf, and enroll me in the plan, to remain my agent of record, renew my plan annually, and make any changes necessary to keep my plan active, including submitting any required documents on my behalf using the information I provided today. I authorize the agent to submit my application.
