Health App Form

I certify that I have received a copy of the Privacy Policy and that I have entered all information in the Health Insurance Marketplace truthfully and accurately. I attest that I have created a dedicated email address to use for all correspondence to and from the Health Insurance Marketplace and/or Remco Insurance Services, Inc. or its affiliates. The information supplied on this application and any signed addendum is accurate and complete to the best of my knowledge. No material information has been written or omitted on any person applying. I understand that if my signature and date do not appear and/or my answers are incomplete, that application will be either rejected or returned for completion.

George Kalashnikov

Health & Life Specialist